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INTESTINAL       LESIONS 


Fiy.3 


TYPHOID       FEVER.. 


TEXT-BOOK 


ERUPTIVE  AND  CONTINUED  FEVERS. 


BY 

JOHN  WILLIAM  MOORE,  B.A.,  M.D.,  M.CH.,  UNIV.  DUBL.; 

FELLOW   AND    REGISTRAR   OF   THE   EOYAL   COLLEGE    OF   PHYSICIANS   OF   IRELAND; 

PHYSICIAN    TO    THE    MEATH    HOSPITAL,    DUBLIN  ; 

JOINT   PROFESSOR    OF   PRACTICE   OF   MEDICINE   IN   THE   SCHOOLS   OF    SURGERY   OF   THE 

ROYAL    COLLEGE    OF   SURGEONS   IN   IRELAND  ; 

CONSULTING   PHYSICIAN   TO    CORK-STREET   FEVER   HOSPITAL,    DUBLIN,    AND   TO   THE 

WHITWORTH   HOSPITAL,    DRUMCONDRA  ; 
EX-SCHOLAR   AND    DIPLOMATE   IN  STATE   MEDICINE    OF   TRINITY    COLLEGE,    DUBLIN. 


WILLIAM     WOOt)     &     COMPANY 

MEDICAL  PUBLISHERS, 

NEW  YORK. 

1892. 


&0    t\t    nfurea    HUmorg    of 
MY  FATHER, 

WILLIAM    DANIEL    MOORE, 

M.D.  Dubl.  et  Cantab.,  M.R.I.A., 
{April  19,  1813— October  28,  1871), 

I      DEDICATE      THIS      BOOK. 


PBEFACE. 


It  may  be  desirable  to  state  very  briefly  the  circumstances 
under  which  this  work  has  come  to  see  the  light. 

To  write  a  Text-book  on  Fever  while  the  splendid  mono- 
graph of  Charles  Murchison  is  our  possession  to  all  time  may 
well  be  deemed  presumptuous.  But,  on  the  threshold,  I 
would  disclaim  any  intention  of  allowing  the  present  work — 
"  hoc  parvum  opusculum  " — to  enter  the  lists  with  that 
unrivalled  masterpiece.  However,  even  since  Dr.  William 
Cay  ley,  in  1884,  edited,  with  excellent  good  taste  and  literary 
skill,  the  posthumous  edition  of  Murchison's  Treatise,  the 
study  of  the  Continued  Fevers  has  received  a  great  impetus, 
and  the  necessity  of  a  sound  knowledge  of  Fever  by  every 
practitioner  of  medicine  has  been  more  and  more  recognised. 
As  regards  the  Eruptive  Fevers,  we  possess  no  work  at  all 
analogous  to,  or  comparable  with,  that  of  Murchison  on  the 
Continued  Fevers.  It  is  true  that  a  very  full  and  accurate 
description  of  these  diseases  is  to  be  found  in  the  third  edition 
of  Hilton  Fagge's  and  Pye-Smith's  "  Text-book  of  the  Prin- 
ciples and  Practice  of  Medicine,"  published  in  1891,  The 
standard  works  on  Practice  of  Medicine  also  contain  a  number 
of  chapters  devoted  to  this  subject;  and  I  am  aware  that 
a  Text-book  upon  the  Eruptive  Fevers  by  Dr.  Alexander 
Collie  has  been  published  within  the  last  few  years. 

Notwithstanding  all  this,,  I  make  bold  to  say  that  full 
justice  has  not  up  to  the  present  been  done  to  so  important 
and  fascinating  a  theme.  While  I  cannot  pretend  to  have 
adequately  supplied  an  admitted  want  in  medical  literature-r- 


Ylll  PREFACE. 

namely,  a  reliable  and  comprehensive  Text-book  of  the 
Eruptive  Fevers,  yet  I  have  endeavoured  to  focus  in  its 
pages  the  most  recent  views  on  the  aetiology,  bacteriology, 
symptoms,  pathology,  and  treatment  of  this  group  of  maladies. 

Of  late  years  the  Spirit  of  Scientific  Discovery  has  been 
abroad.  In  the  realms  of  both  Curative  and  Preventive 
Medicine  its  presence  has  been  felt,  but  in  no  direction  more 
than  in  the  fertile  field  of  Bacteriology.  The  microbic 
origin  of  enteric  fever,  erysipelas,  pneumonia,  cholera,  and 
diphtheria,  has  been  practically  demonstrated,  and  kindred 
investigations  are  still  engaging  the  earnest  attention  of  the 
foremost  thinkers  in  this  country,  on  the  Continent,  and  in 
America.  We  are  not  yet  in  a  position  fairly  or  accurately 
to  gauge  the  gain  to  Humanity  and  to  Science  which  will 
accrue  from  such  researches  as  those  of  Burdon-Sanderson 
and  E.  Klein,  of  Robert  Koch,  of  Louis  Pasteur  and  Toussaint, 
and  of  other  toilers  in  the  vast  field  of  original  investiga- 
tion, but  they  bear  glowing  testimony  to  the  advance,  by 
leaps  and  bounds,  of  Medical  Science.  They  teach  the 
lesson — so  full  of  encouragement  to  the  God-fearing  and  man- 
loving  physician — that,  in  the  not  distant  future,  success  will 
surely  crown  his  noble  effort  to  combat  disease,  to  save  life, 
and  to  stem  the  rising  tide  of  human  misery  and  despair. 

The  study  of  Fever  has  always  had  a  peculiar  attraction 
for  me.  Perhaps  this  arose  in  part  from  the  fortunate  cir- 
cumstance that  as  a  medical  student  I  enjoyed  the  advantage 
of  the  philosophic  teaching  of  William  Stokes  and  was  a  daily 
witness  of  the  lynx-eyed  observation  of  Alfred  Hudson  in  the 
wards  of  the  Meath  Hospital.  These  are  names  to  conjure 
with  from  the  bead-roll  of  authors  upon  Fever. 

But  above  and  beyond  this  personal  consideration,  it  has 
always  seemed  to  me  that  each  individual  case  of  Fever  pre- 
sented to  the  attending  physician  or  to  the  clinical  student 
an  epitome  of  the  Principles  and  Practice  of  Medicine. 


PREFACE.  ix 

"  Fever,"  said  Fordyce,  nearly  a  century  ago,  "is  a  disease 
which  affects  the  whole  system ;  it  affects  the  head,  trunk, 
and  extremities ;  it  affects  the  circulation,  absorption,  and 
the  nervous  system ;  it  affects  the  body,  and  it  affects  the 
mind ;  it  is  therefore  a  disease  of  the  whole  system,  in  the 
fullest  sense  of  the  term."  This  being  so,  we  surely  are  in  a 
position  to  study  diseases  of  the  three  great  cavities  of  the 
body,  diseases  of  the  circulation,  of  the  lymphatic,  digestive, 
and  nervous  systems  in  an  individual  case  of  fever.  If  our 
object  is — as  it  should  be — to  accurately  gauge  the  state  of 
our  fever  patient,  we  cannot  attain  this  end  by  a  mere  super- 
ficial examination.  On  the  contrary,  every  known  method  of 
physical  examination  must  be  applied,  and  this  too  as  regards 
every  system  of  the  body  in  rotation. 

It  would  be  equally  disastrous  to  our  fever  patients  were 
we,  on  the  one  hand,  to  treat  a  case  which  showed  cerebral 
symptoms  as  if  inflammation  of  the  brain  or  its  membranes 
was  really  present,  were  we,  on  the  other  hand,  to  act  upon 
the  unwarranted  assumption  that  the  kidneys  in  a  given 
patient  were  sound  and  efficient. 

In  a  word,  there  is  no  other  disease  which  demands  on  the 
part  of  the  physician  a  closer  and  more  intelligent  observa- 
tion, a  more  minute  and  searching  physical  examination,  a 
more  subtle  and  refined  train  of  reasoning,  a  more  careful 
weighing  of  evidence  for  or  against,  and  a  more  conscientious 
and  painstaking  management  from  start  to  finish. 

The  Royal  College  of  Physicians  of  Ireland — to  their  credit 
be  it  spoken — many  years  ago  recognised  the  paramount 
importance  of  a  close  study  of  fever  by  all  candidates  for  the 
License  to  Practise  Medicine  granted  by  the  College.  The 
President  and  Fellows  required,  and  still  require,  that  every 
candidate  for  that  License  shall  produce  evidence  of  having 
for  not  less  than  three  months  studied  Fever  in  a  recognised 
Clinical  Hospital  containing  fever-wards,  and  of  having  re- 


X  PREFACE. 

corded,  from  daily  personal  observation,  the  notes  of  at  least 
five  cases  of  fever  to  the  satisfaction  of  the  attending  clinical 
physician,  as  attested  by  his  signature. 

The  University  of  Dublin  requires  of  all  candidates  for  the 
degree  of  Bachelor  in  Medicine  or  for  the  Diploma  in  Medi- 
cine a  certificate  of  personal  attendance  on  Fever  Cases,  with 
the  names  and  dates  of  the  cases  attended. 

The  Royal  University  of  Ireland  requires  evidence  of  per- 
sonal attendance  on  at  least  ten  fever  cases  during  three  con- 
secutive months  in  a  Fever  Hospital  of  repute,  or  in  the  fever 
wards  of  a  General  Hospital. 

The  Irish  Medical  Licensing  Bodies  have  thus  nothing  to 
be  ashamed  of  in  so  important  a  matter. 

At  their  Summer  Session  in  1890,  the  General  Medical 
Council,  on  June  5,  adopted  the  following  resolution : — 

"Resolved, —  That  no  qualification  in  Medicine  ought  to 
be  granted  without  evidence  of  clinical  instruction  in 
Infectious  Diseases." 

This  resolution  was  adopted  in  consequence  of  the  receipt 
of  a  communication  from  the  Local  Authority  for  Glasgow 
under  the  Public  Health  (Scotland)  Act.  To  this  body 
belongs,  therefore,  the  credit  of  initiating  this  important 
public  recognition  of  the  Clinical  Study  of  Fever. 

It  is,  therefore,  plain  that  in  future  a  personal  study  of 
fever  will  be  an  indispensable  part  of  medical  education. 

This  was  one  of  the  considerations  which  led  me  to  write  a 
book  which,  I  hoped,  might  serve  as  a  reliable  guide  to  the 
student  of  fever. 

In  the  spring  of  1891,  the  Trustees  of  the  Queen  Victoria 
Jubilee  Nursing  Institute  asked  me  to  deliver  a  course  of 
lectures  on  Fevers  and  Fever-Nursing  to  the  nurses  and 
probationers  who  were  working  under  the  auspices  of  the 
Institute  among  the  sick-poor  of  Dublin  and  its  suburbs  in 
their  own  homes.     The  notes  which  I  compiled  for  that 


PUEFACE.  XI 

course  of  lectures  first  suggested  the  idea  of  publishing  a  book 
on  the  Nature  and  Treatment  of  Fever. 

As  to  any  special  qualifications  for  my  self-imposed  task,  I 
can  lay  claim  to  none,  beyond  the  fact  that  for  a  period  of 
thirteen  years  I  was  one  of  the  Visiting  Physicians  to  Cork- 
street  Fever  Hospital,  Dublin. 

It  may,  perhaps,  be  objected  that  in  writing  this  book  I 
have  leaned  too  much  on  the  clinical  experience  and  on  the 
literary  labours  of  others.  No  doubt  the  following  pages 
bristle  with  the  names  of  authorities ;  but  I  have  always 
endeavoured  to  test  their  statements  by  the  touchstone  of 
my  own  experience,  nor  have  1  hesitated  to  freely  criticise 
any  observations  or  opinions  apparently  unwarranted  by 
certain  facts,  which  appeared  to  me  to  be,  perhaps,  capable 
of  a  different  interpretation. 

It  may  be  necessary  to  observe  that  all  the  Temperature 
Charts  in  the  nine  Plates  which  illustrate  this  book  are,  with 
three  exceptions — the  two  charts  of  the  temperature  ranges 
in  relapsing  fever  and  the  chart  which  shows  a  crisis  in 
enteric  fever,  and  which  I  owe  to  the  kindness  of  Dr.  H.  T. 
Bewley — reproduced  from  among  many  hundreds  taken  in 
my  own  cases  at  Cork-street  Fever  Hospital  and  at  the 
Meath  Hospital. 

The  pleasant  task  remains  of  expressing  my  grateful 
acknowledgments  to  several  friends  who  kindly  helped  me 
in  my  work.  My  cordial  thanks  are  especially  due  to  Dr. 
H.  T.  Bewley,  Assistant  Physician  to  the  Adelaide  Hospital, 
and  Dr.  Edward  E.  Lennon,  Senior  Clinical  Assistant  to  the 
Meath  Hospital,  who  undertook  the  labour  of  reading  over 
the  proof  sheets  as  they  issued  from  the  press.  To  them, 
and  also  to  Dr.  James  Little,  Dr.  T.  W.  Grimshaw,  Regis- 
trar-General for  Ireland,  Dr.  Walter  G.  Smith,  and  Dr.  C. 
J.  Nixon,  I  am  deeply  indebted  for  valuable  suggestions  and 
useful  references. 


XU  PREFACE. 

Nor  should  I  omit  to  mention  the  trouble  taken  in  search- 
ing out  books  and  original  papers  by  Mr.  S.  W.  Wilson,  the 
Librarian  of  the  Royal  College  of  Physicians  of  Ireland  on 
the  Foundation  of  Sir  Patrick  Dun. 

I  desire  also  to  acknowledge  the  courtesy  of  Dr.  William 
Cayley,  the  editor  of  the  third  edition  of  Murchison's  work 
on  the  "  Continued  Fevers,"  and  of  the  eminent  firm  of 
publishers,  Messrs.  Longmans,  Green,  &  Co.,  in  permitting 
me  to  reproduce  a  series  of  very  instructive  Diagrams  from 
that  work. 

In  conclusion,  I  can  but  express  the  hope  that  the  following 
pages  will  prove  useful  to  some  of  that  devoted  band  who 
have  already  entered,  or  are  about  to  enter,  upon  the  practice 
of  the  noblest  of  all  Professions — the  Church  not  even  ex- 
cepted. 

JOHN  WILLIAM  MOOEE. 

40  FlTZWILLIAM-SQUABE,  WEST,  DUBLIN, 

Decemhr  21st,  1891. 


CONTENTS. 


PART     I. -INTRODUCTION. 

CHAPTER  I. 

The  Intimate  Nature  of  Fever. 

Page 
Meaning  of  the  terms  "Fever"  and  "Pyrexia." — Pyrexia,  or  "Feverish- 
ness,"  is  either  primary  (idiopathic,  specific,  or  essential  Fever)  or  secondary 
(symptomatic,  non-specific,  or  non-essential  Fever). — Definitions  of  Fever. — 
Theory  of  Animal  Heat. — The  "Thermal  Apparatus"  (Maclagan). — The 
"  Thermal  Nervous  System "  (Donald  Macalister). — The  Neurotic  and 
Metabolic  Theories  of  Fever. — Cantani's  views  as  to  the  nature  and  use  of  the 
Fever  Process. — "Das  Heil-Fieber." — The  Pathology  of  the  Infective  or 
Specific  Fevers. — The  Essential  Phenoraeua  of  Fever. — Why  does  the  Fever 
Patient  waste  ? — Why  is  he  thirsty  ? — How  may  water  be  supplied  to  the 
Fever  Patient  1 — The  therapeutical  uses  of  water  1 

CHAPTER  II. 

The  Intimate  Nature  of  Contagion. 

Communicable  and  Non-communicable  Diseases. — The  "  Germ  Theory  of 
Disease." — Meanings  of  the  term  "Contagion." — Zymotic  Diseases. — A  typical 
example  of  Fermentation. — Nageli's  Classification  of  the  decomposition-pro- 
ducing Fungi :  Moulds,  Yeasts,  Fission-fungi  (including  Bacteria).— Characters 
and  sub-divisions  of  the  Fission-fungi,  or  Schizomycetes. — Non-pathogenic 
l\Jicro-organisms  or  Microbes  (Saprophytes). — Pathogenic  Micro-organisms 
or  Microbes  (Parasites). — Division  of  the  latter  into — (1.)  Non-infectious,  but 
toxic,  organisms  ;  (2.)  Truly  infectious  organisms. — Toxins,  or  Ptomains. — 
Crookshank's  Classification  of  Bacteria. — Aerobic  and  Non-aerobic  Micro- 
organisms (Pasteur):  their  food  and  drink. — ISporulation :  "Resting  Spores." — 
Explanation  of  supposed  spontaneous,  or  de  novo,  origin  of  Infectious  Fevers. — 
Specific,  infective  microbe,  virus,  or  contagium. — Seat  of  the  Development  of 
the  several  Contagia. — Inoculation. — "Contagious"  and  "Infectious"  Diseases         12 


XIV  CONTENTS. 

CHAPTER  III. 

Micro-parasitic  Diseases. 


Page 


Substitution  of  this  term  for  "Zymotic  Diseases." — "Infective  Diseases." — 
Liebermeister's  Classification:  1,  Miasmatic;  2,  Miasmatic-Contagious;  3, 
Parasitic-Contagious  (Infectious  or  Contagious). — Endemic,  Epidemic,  Sporadic, 
and  Pandemic  :  definition  of  these  terms. — Theories  of  Immunity. — Natural 
and  Acquired  Immunity. — Metschnikoff's  theory  of  Phagocytosis. — Phago- 
cytes (Germ.  "  Fresszellen  "). — "  Micro-Strife  "  (A.  Wynter  Blyth). — Acquired 
Immunity. — Classification  of  Micro-parasitic  Febrile  Diseases  :  1,  The  Eruptive 
Fevers  or  Exanthemata  ;  2,  The  Contin  ued  Fevers ;  3,  The  Intermittent 
Fevers. — Cyclical  course  of  the  Specific  or  Essential  Fevers:  1,  Incubation; 
2,  Invasion ;  3,  Eruption  ;  4,  Defervescence ;"  5,  Desquamation  ;  6,  Convales- 
cence.— Quarantine. — Isolation. — -Influence  of  the  Micro -parasitic  Diseases  on 
e;  ch  other  --......-18 

CHAPTER  IV. 

The  General  Principles  op  Treatment  op  the  Eruptive  and  Continued  Fevers. 

part  i. — preventive  treatment,  or  prophylaxis. 

Preventable  Diseases. — Preventive  Treatment,  or  Prophylaxis. — Disinfec- 
tion : — Antiseptics,  Disinfectants,  Germicides,  and  Deodorants.— Dr.  Shelly's 
Classification  of  Disinfectants. — Dr.  Emerson  Reynolds'  General  Plan  of 
Disinfection. — Official  Regulations  for  Disinfection  adopted  in  Berlin. — 
Disinfection  within  the  Living  Body. — Receptivity. — Exciting  and  Predis- 
posing Causes  of  Disease. — Acquired  and  Natural,  or  Hereditary,  Predisposition 
to  Disease. — The  chief  Predisposing  Causes  of  Febrile  Disorders  -  -         30 

CHAPTER  V. 

The  General  Principles  of  Treatment  of  the  Eruptive  and  Continued  Fevers. 

part  ii. — curative  treatment. 

Principles  of  Treatment  of  Fevers— 1.  To  neutralise  the  Fever  Poison: 
sanitary  surroundings,  mineral  acids,  antiseptics. — 2.  To  promote  elimination  : 
fresh  air,  diluents,  diuretics,  diaphoretics,  aperients  or  laxatives,  beneficial 
effects  of  common  salt  (chloride  of  sodium). — 3.  To  reduce  temperature  : 
hygienic  measures — bloodletting  (general  or  local),  saline  cathartics,  diaphoretics, 
antipyretics  (Cantani's  Views  on  Antipyresis)  ;  cold  water  treatment— tepid 
sponging,  the  wet-pack,  the  application  of  ice-cold  compresses,  the  cold  bath, 
the  ice-cradle  (Fenwick). — 4.  To  maintain  nutrition:  food  to  be  both  nutri- 
tious and  digestible,  peptonised  food,  times  for  feeding  the  fever  patient, 
feeding  through  the  nares  or  by  the  rectum  ;  administration  of  alcoholic 
stimulants— indications  for  their  use,  signs  of  their  agreeing  with  the  patient, 
avoidance  of  exhaustion. — 5.  To  relieve  distressing  symptoms  :  headache, 
sleeplessness,  nervous  excitement,  delirium,  stupor,  convulsions,  hyperesthesia, 
rheumatoid  and  neuralgic  pains,  thirst,  persistent  vomiting,  tymp-inites  or 
meteorism,  hiccough,  diarrhoea,  intestinal   haemorrhage. — 6.  To  obviate  and 

COUNTERACT  LOCAL  COMPLICATIONS  AND  SEQUELS       -       -       -       -     48 


CONTENTS.  XV 

PART  II.— THE  EXANTHEMATA,  OR  ERUPTIVE  FEVERS. 

CHAPTER  VI. 

General  Considerations. 

Page 
Cullen's  classification  of  Diseases. — Four  Orders  of  Pyrexiae. — Definition  of 

the  Exanthemata. — Meaning  of  the  term  ££d.v6wf*a.. — Enumeration  of  the 
common  acute  Micro-parasitic  Diseases  which  are  called  "Eruptive  Fevers." — 
Smallpox,  the  "  paradigm  "  or  type         ......        gy 

CHAPTER  VII. 

Variola,  or  Smallpox. 

Nomenclature. — Definition. — Etiology  (historical  sketch).  — Exciting  cause  : 
contagion. — Predisposing  causes  :  susceptibility,  from  non-protection,  season, 
race. —  Bacteriology  of  Smallpox. — Modes  of  dispersion  of  th^  morbid  poison. — 
"  Striking  Distance  "  of  the  disease. — Chief  Stages  of  Infectiveness. — Clinical 
History  :  Incubation,  Invasion,  Eruption  (its  five  stages  of  development : 
Specks  of  Hypersemia,  Papules  or  Pimples,  Vesicles,  Pustules,  Scabs  or  Crusts), 
Desiccation,  Desquamation. — Variolous  Exanthem  upon  the  Mucous  Mem- 
branes, but  not  upon  the  Serous  Membranes       -----         69 

CHAPTER  VIII. 

Smallpox  (continued). 

CLASSIFICATION    AND   VARIETIES. 

Classification  of  Smallpox  based  upon  the  distribution  and  amount  of  the 
Rash :  Variola  discrbta,  confluens,  coh^erens,  cortmbosa. — Symptoms  of 
Confluent  Smallpox  :  its  mortality  and  sequelae. — Meaning  of  the  terms  "  Semi- 
confluent  "or  "Coherent,"  and  "Corymbose,"  Smallpox. — The  latter  said  to 
be  a  very  fatal  variety    -  -  -  -  -  -  -  -82 

CHAPTER  IX. 

Smallpox  (continued). 

TEMPERATURE. — VARIETIES. — COMPLICATIONS.— PATHOLOGY. — DIAGNOSIS. — PROGNOSIS 

Temperature  :  Two  distinct  Types  of  Fever  in  Smallpox— viz.  1.  A  brief 
continuous  Fever  ;  2.  A  relapsing  Fever. — Prodromal  or  Initial  Fever. — 
Secondary  Fever,  or  Fever  of  Suppuration  or  of  Maturation. — Hyperpyrexial 
Temperature  in  Fatal  Cases. — Varieties  of  Smallpox  :  Discrete,  Confluent, 
Benign  or  Varioloid — 1.  Variola  sine  Exanthemate,  2.  V.  cornea  (Hornpox), 
3.  V.  verrucosa  (Wartpox)  ;  Malignant  (V.  maligna) — 1.  Purpuric,  2.  Haemor- 
rhagic  (Purpura  variolosa),  3.  V.  hemorrhagica  pustulosa  of  Curschmann, 
V.  nigra?  of  Sydenham,  V.  cruentse.—  Table  of  the  varieties  of  Smallpox. 
Complications  and  Sequels,  affecting  the  skin,  eyes,  ears,  nose,  tongue, 
larynx,  respiratory  organs,  digestive  organs,  circulatory  system,  kidneys, 
nervous  system,  genitals,  blood,  joints. — Pathology  :  Morbid  anatomy  and 
histology. — Diagnosis,  Prognosis,  and  Mortality    -  -  -  87 


XVI  CONTENTS. 

CHAPTER  X. 

The  Preventive  Treatment  of  Smallpox. 

Page 
Smallpox  communicable  ;  but  one  attack  confers  immunity  from  a  second. — 
Preventive  Measures  :  1.  Isolation  ;  2.  Inoculation  ;  3.  Vaccination. — 
Inoculation  illegal. — History  of  Inoculation.  —  Clavelisation. — History  of 
Vaccination. — Value  of  Vaccination  in  controlling  prevalence  and  mortality  of 
Smallpox. — Marson's  views  as  to  the  use  of  Multiple  Vaccinal  Cicatrices. — 
Periodical  Revaccination.  —  Circumstances  which  conduce  to  success  of 
Vaccination.— Jenner's  "Golden  Rule." — Bovine  and  Humanised  Lymph. — 
Performance  of  Vaccination. — Bryce's  Test. — Vaccina  :  its  local  and  consti- 
tutional symptons.— Vaccino-stphilis.  .....      102 

CHAPTER  XI. 

The  Cdrative  Treatment  of  Smallpox. 

No  specific  for  Smallpox — two  great  Principles  of  Treatment  :  (1)  to 
guide  the  essential  disorder,  (2)  to  combat  secondary  affections. — "Hot  Regi- 
men "  treatment  of  olden  times. — Thomas  Sydenham's  "Cooling  Regimen." — 
Treatment  of  Discrete,  Confluent,  and  Hsemorrhagic  Smallpox. —Two  dangers 
in  Confluent  Smallpox  :  general  blood-poisoning,  and  exhaustion. — Antiseptic 
Treatment. — Prevention  of  "Pitting." — Dr.  Stokes's  views. — Three  Indica- 
tions for  Treatment  :  (1)  to  exclude  air,  (2)  to  keep  the  surface  in  a  perma- 
nently moist  state,  (3)  to  lessen  the  local  irritation. — Hebra's  Treatment  by 
the  Warm  Bath. — Dr.  Stokes's  account  of  this  method. — Hebra's  apparatus  for 
the  Continual  Bath. — Treatment  of  Affections  of  the  Skin  in  Smallpox,  and  of 
the  various  Local  Affections. — Turpentine  and  Ergot  in  Haemorrhage. — Trans- 
fusion of  Blood.  ---------       113 

CHAPTER  XII. 

Varicella,  or  Chickenpox. 

Nomenclature. — Derivation  of  the  term  "  Chickenpox." — Definition. — 
^Etiology  (historical  sketch). — Clinical  History  :  Incubation,  Invasion,  Erup- 
tion, Desiccation. — No  secondary  Fever. — Not  a  fatal  Disease. — Complications 
and  Sequela?  :  Varicella  gangraenosa  (Jonathan  Hutchinson). — Dermatitis 
gaagraenosa  — "  Varicella-prurigo  "  (J.  Hutchinson). — Diagnosis  from  Lichen, 
Herpes,  Pemphigus,  and  Varioloid. — Prognosis  and  Treatment.  -  -       125 

CHAPTER  XIII. 

Morbilli,  or  Measles. 

Nomenclature. — Definition. — ^Etiology. — Bacteriology. — Chief  Stages  of 
Infectiveness. — Epidemics  in  Faroe  Islands  and  in  Fiji. — Seasonal  Preva- 
lence :  Measles  a  disease  of  Spring  and  Autumn. — Clinical  History  : 
Incubation,  Invasion,  Eruption,  Desquamation. — Furfuraceous  Desquama- 
tion.— Convalescence  complete  on  the  Eighteenth  Day.  -  -       133 


CONTENTS;  xvii 

CHAPTER  XIV. 

Measles  (continued). 

CLASSIFICATION.  — COMPLICATIONS. — TEMPERATURE. — PATHOLOGY. — DIAGNOSIS. — 

PROGNOSIS. 

IJage 

Classification  of  Measles:  Niemeyer's.— Benign  and  Malignant. — 
Benign  :  Morbilli  sine  catarrho  ;  Morbilli  sine  morbillis.  Malignant :  Purpuric 
Measles  ;  Asthenic  or  Adynamic  Measles  ;  Complicated  Measles. — Causes  of 
Complications  (Hebra).  —Complications  of  the  staee  of  invasion :  Convulsions, 
spasmodic  catarrhal  laryngitis  (false-croup),  suffocative  catarrh,  epistaxis,  otitis, 
diarrhoea,  colitis  ;  of  the  stage  of  eruption  :  morbillous  diarrhoea,  capillary 
bronchitis,  pneumonia,  diphtheria  (true-croup)  ;  of  the  stage  of  desquamation  : 
glandular  enlargements,  otitis,  cancrum  oris  (noma),  gangrene  of  the  vulva, 
acute  desquamative  nephritis,  acute  miliary  tuberculosis,  herpes,  eczema,  etc., 
pleuritis,  chronic  ophthalmia,  atrophic  keratitis. — Temper  \ture  in  measles. — 
Pathology.  —  Diagnosis  :  from  epidemic  rose-rash,  scarlatina,  smallpox 
(Grisolle  sign),  varicella,  simple  rose-rashes,  typhus. — Prognosis  -  -       142 

CHAPTER  XV. 

The  Treatment  of  Measles. 

Prophylaxis  :  quarantine,  isolation,  hygienic  measures. — Curative  Treat- 
ment :  no  specific  for  measles — treatment  is  symptomatic  and  hygienic. 
Treatment  of  Complications  :  Malignant  Measles — cool  baths  (Dieulafoy). — 
Initial  convulsions,  false  and  true  croup,  epistaxis,  otitis,  diarrhoea,  ophthalmia, 
glandular  enlargements,  noma,  gangrene  of  the  vulva,  acute  tuberculosis  -       150 

CHAPTER  XVI. 

Scarlatina,  or  Scarl£t  Fever. 

Nomenclature. —Definition. — ./Etiology  (historical  sketch). — Area  of  Diffu- 
sion.— Epidemic  and  sporadic  outbreaks  — Rate  of  Mortality  most  variable. — 
Predisposing  Causes  :  Climatic  influences  ;  season. — Exciting  Cause  :  Spe- 
cific poison — "Contagium  Vivum." — Professor  Klein's  Researches:  Streptococcus 
scarlatinas. — Hendon  Cow  Diseasf. — Clinical  History  :  Scarlatina  simplex, 
anginosa,  and  maligna. — Varieties  of  Scarlatina  simplex. —  Stages  of  Incuba- 
tion, Invasion,  Eruption,  Desquamation. — Prominent  Symptoms  :  Vomiting, 
sore-throat,  tache  scarlatinale,  "strawberry-tongue,"  albuminuria  -  .       154 

CHAPTER  XVII. 

Scarlatina  (continued). 

aberrant  forms. — complications  and  sequels. — temperature. 

Irregular  or  aberrant  forms  of  scarlatina  :  (1.)  Rudimentary  or  abor- 
tive :  (a.)  simple  scarlatinal  angina  (scarlatina  faucium),  (/3.)  latent  scarlatina 
(scarlatiue  fruste)  ;  (2.)  Scarlatina  anginosa — diffuse  cellulitis  of  neck  ("  tippet- 

b 


CONTENTS. 


neck"),  diphtheria  ;  (3.)  Scarlatina  maligna  :  (a.)  Angina  maligna,  (13.)  ataxic 
scarlatina,  (7.)  hsemorrhagic  scarlatina — "Scharlachtyphus." — Complications 
and  Sequelae  :  Diphtheria,  acute  rheumatic  arthritis  and  serous  inflammations, 
acute  desquamative  nephritis,  pleuritis,  bubonic  swellings,  pyaemia,  boils  and 
abscesses,  otitis,  eye  affections,  eczema,  chorea. — Temperature  ranges  in 
Scarlatina  .........       \qq 


CHAPTER  XVIIL 

Scarlatina  (continued). 

Pathology,  Diagnosis,  and  Prognosis. 

Pathology  of  Scarlatina  :  The  blood — the  cutaneous  affection — the  throat 
and  sub-maxillary  glands. — Cerebro-spinal  system. — The  abdomen — small 
intestine — psorenterie  —  kidneys . —  G-lomerulo-tubal  Nephritis  (Klebs). — E. 
Klein's  views. — Diphtheritic  Pyelitis. — Changes  in  the  urine.  — Dropsy. — 
Inflammations  of  (a.)  serous  membranes,  (/3.)  of  synovial  membranes  of  the 
j  lints. — The  heart — acute  parenchymatous  myocarditis — cardiac  failure. — 
Diagnosis  :  Erythema,  Smallpox,  Measles,  Rotheln,  Erysipelas,  Diphtheria, 
Acute  Rheumatism. — Prognosis  and  Mortality. — Causes  of  Death    -  -       173 


CHAPTER  XIX. 

The  Treatment  of  Scarlatina. 

Prophylaxis  not  so  difficult  of  attainment  as  in  the  case  of  Measles. — Sug- 
gested prophylaxis  by  drugs  not  reliable.  — Effectual  prophylaxis  consists  in 
Isolation. — Curative  Treatment  :  no  antidote  yet  discovered.— Biniodide  of 
Mercury  (Illingworth). — Treatment  must  be  largely  symptomatic. — Treatment 
of  Scarlatina  simplex  :  expectant. —Hebra's  recommendations. — Guaiacum 
and  Ozonic  Ether  Test  for  Blood-pigment  in  Urine. — Treatment  of  Scarla- 
tina anginosa  :  cold  water  treatment,  quinine,  ice,  cold  compresses  to  neck, 
drugs. — Treatment  of  Scarlatina  maligna:  combat  ataxic  symptoms  ;  in 
haemorrhage,  use  local  and  general  astringents. — Treatment  of  Complications 
and  Sequelae  :  Diphtheria,  rheumatism,  acute  desquamative  nephritis,  ursemic 
convulsions,  pleuritis,  endocarditis,  bubonic  swellings,  diffui-e  cellulitis,  pyaemia, 
acute  furuncular  diathesis,  diseases  of  the  ear,  conjunctivitis,  keratitis,  acute 
eczema,  chorea    -  -   .  -  -  -  -  -  -  -       l!-2 


CHAPTER   XX. 

Rotheln,  or  Epidemic  Rose  Rash. 

Nomenclature. — Definition. — ^Etiology  (historical  sketch). — Clinical  His- 
tory :  Incubation,  invasion,  eruption,  desquamation. — Temperature. — Com- 
plications and  Sequelae. — Pathology. —  Diagnosis. — Claims  of  Rotheln  to  be 
considered  a  distinct  disease. — Prognosis  :  entirely  favourable. — Treatment    -       193 


CONTENTS.  XIX 


CHAPTER  xxr. 

Erysipelas. 


Page 


r  Nomenclature. — Definition. — iEtiology. — Erysipelas  both  a  local  and  a 
specific  disease. — Medical  or  Idiopathic  and  Surgical  or  Traumatic  Erysi- 
pelas.— Predisposing  Causes  :  traumatism,  a  previous  attack,  sex,  age, 
climate,  season. — Exciting  Causes  :  contagion,  inoculation.  Doctrine  of  the 
Contagiousness  of  Erysipelas  is  now  proved. — Bacteriology  :  Streptococcus 
Eryxipelatis  (Fehleisen)  --------       202 

CHAPTER  XXII. 

Erysipelas  {continued). 

clinical  history — temperature — diagnosis — Prognosis  and  mortality. 

Clinical  History. — Varieties  of  Erysipelas  according  to  depth  of  surface 
affected  :  (1.)  Simple  or  cutaneous  ;  (2.)  Phlegmonous,  or  cellulo-cutaneous  ; 
(?.)  Diffuse  cellulitis. — Stages  of  incubation,  invasion,  eruption,  defervescence. 
Erysipelas  faucium,  pulmonurn. — Temperature. — Diagnosis. — Prognosis  and 
Mortality  .........       21(1 

CHAPTER  XXIII. 

Treatment  of  Erysipelas. 

Expectant  Treatment. — Constitutional  (or  General)  and  Topical  Treat- 
ment.— Constitutional  Treatment  :  tincture  of  the  perohloride  of  iron, 
quinine,  ammonia  and  bark  in  effervescence,  salicylate  of  sodium  (Hallopeau), 
cold  baths,  alcoholic  stimulants,  effervescing  draughts  in  gastro-intestinal  dis- 
turbance, opium  or  morphin  in  threatening  delirium. — Topical,  or  Local 
Treatment  :  indications — (1.)  to  relieve  pain  and  tension;  (2.)  to  check  the 
spread  of  inflammation  ;  (3.)  to  destroy  the  infectious  matter  in  situ. — Leeches 
are  contra-indicated. — "Ectrotic"  method. — Topical  use  of  nitrate  of  silver. — 
Rectified  oil  of  turpentine. — Sulpho-carbolate  of  sodium. — Sprays. — Special 
treatment  of  oedema  of  the  eyelids,  sore  tbroat,  laryngitis,  and  cedema  of  the 
glottis,  tension  of  the  skin,  gangrene       ......       221 


PAET  III.— THE  CONTINUED  FEVERS. 


CHAPTER  XXIV. 

General  Considerations. 

Classification  into  Exanthemata,  Continued  Fevers,  and  Intermittent 
Fevers  is  non-essential  but  convenient. — Claims  of  Typhus  and  Typhoid  or 
Enteric  Fevers  to  be  classed  as  Exanthemata.  Three  reasons  why  they  are 
not  so-classed. — Cullen's  definition  of  the  Continued  Fevers. — Murchison's 
classification  of  these  Fevers.    Objections  advanced  to  certain  of  his  statements        229 


XX  CONTENTS. 

CHAPTER  XXV. 

Febricula,  or  Simple  Fever. 


Page 


Nomenclature. — Definition. — ^Etiology  and  History. — Probably  of  specific 
origin,  like  the  otherfevers — probably  auto-infective — Clinical  History  :  Four 
Forms — 1.  Ephemera  ;  2.  Synocha,  or  Acute  Inflammatory  Fever  ;  3.  Ardent 
Continued  Fever  of  the  Tropics  ;  4.  Asthenic  Simple  Fever. — Diagnosis. — 
Prognosis. — Pathology. — Treatment.      ------       233 

CHAPTER  XXVI. 

Typhus  Fever. 

Nomenclature  —  Literature  —  Definition  —  Geographical  Distribution — 
^Etiology — Exciting  and  Predisposing  Causes — Facts  known  relative  to  the 
Specific  Poison  of  Tophus:  1.  Modes  of  infection;  2.  Its  striking  distance 
not  great  ;  3.  Poison  readily  absorbed  by  "  fomites  ; "  4.  Period  of  infec- 
tiousness :  Convalescence  ;  5.  ftlon-inoculable  ;  6.  One  attack  confers  immunity  ; 
7.  Of  light  specific  gravity ;  8.  De>troyed  by  dry  heat ;  9.  Typhus  not  an 
epizootic — Murchison's  doctrine  of  the  spontaneous  generation  of  typhus — 
Proofs  of  its  infectiousness — Arguments  for  and  against  its  spontaneous 
origin — Predisposing  Causes  :  Sex,  Age,  Season,  Temperature  and  Moisture 
in  the  Atmosphere,  Occupation,  Idiosyncracy,  Intemperance,  Bodily  Fatigue, 
Mental  Fatigue  and  Depressing  Emotions,  Previous  Illness,  Recent  Residence 
in  an  infected  district,  Overcrowding  and  Defective  Ventilation,  Destitution 
and  Deficient  Alimentation — Conclusions  ...  -  -       239 

CHAPTER  XXVII. 

Clinical  Description  of  Typhus  Fever. 

Stages  of  Typhus:  (1.)  Incubation — about  twelve  days,  or  less.  (2.)  Inva- 
sion—earliest  symptoms  referable  to  the  Nervous  System.  (3.)  Nervous  Excite- 
ment (Earlier  Eruptive  Stage).  Objective  Symptoms:  typhus  rash,  maculae, 
subcuticular  mottling,  "Mulberry  Rash"  (Jenner).  Delirium:  ferox,  tremens, 
typhomania  (Galen).  (4.)  Nervous  Prostration  (Later  Eruptive  Stage) — 
characterised  by  ataxia  and  adynamia.  Petechia? — the  "  Typhoid  State  " — its 
symptoms.  (5.)  Defervescence  or  Crisis.  Modes  of  Crisis  :  sleep,  slight 
diarrhoea,  diuresis,  perspiration.  (6.)  Convalescence. — Duration  of  Typhun. — 
Blasting  Typhus,  or  T.  siderans. — Typhus  levissimus. — Relapses. — Temperature 
in  Typhus.  —  Hyperpyrexia  -------       2.15 

CHAPTER   XXVIIL 

Analysis  of  the  Chief  Symptoms  of  Typhus. 

The  Surface  :  Fades  typhosa. — Skin  :  maculae  or  petechia?,  sudamina, 
herpes,  poisonous  odour,  which  is  most  infectious ;  branny  desquamation, 
atrophy  of  nails,  laches  bleudtres,  purpura  spots,  vibices,  profuse  sweating — an 
ominous  form  of  crisis. — Circulatory  System  :  Pulse,  vital  condition  of  the 
Heart — Dr.  Stokes's  views — Question  of  stimulants.— Respiratory  System: 
Rate  of  breathing — varieties  of  respiration — Hypostatic  congestion — Breathing 


CONTENTS. 


Page 


offensive.— Djgkstive  System:  Anorexia,  boulimia  in  convalescence — Condi- 
tion of  the  tongue — "  Parrot  Tongue  " — Sordes.  —Diarrhoea. — Urinary  System  : 
Characters  of  the  urine. — Nervous  System  :  Headache,  delirium,  mental 
state,  wakefulness,  "  coma-vigil  "  (Chomel),  "  coma-vigil "  (Jenner),  loss  of 
muscular  strength,  decubitus,  muscular  paralysis,  agitation,  rigidity,  general 
convulsions. — Lesions  of  Organs  op  Special  Sense  :  The  eye,  ear,  nose, 
taste,  sensibility  of  the  skin.        -------       271 

CHAPTER  XXIX. 

Complications  and  Sequels  of  Typhds. 

Causes  of  Complications  in  Typhus.  Complications  affecting  (1)  the  Res- 
piratory Organs  :  Bronchitis,  pneumonia,  gangrene  of  the  lung,  pleurisy, 
tuberculosis,  haemoptysis,  laryngitis.  (2)  The  Blood  and  Circulation  :  Acute 
haemophilia,  pysemia,  venous  thrombosis,  phlegmasia  dolens,  arterial  thrombosis 
and  embolism,  heart  diseases.  (3).  The  Nervous  System  :  Meningitis,  mental 
disease,  paralysis,  neuralgic  and  rheumatoid  pains.  (4).  The  Organs  of 
Digestion  :  Erysipelas  of  the  pharynx,  haetnatemesis,  diarrhoea,  dysentery, 
intestinal  haemorrhage,  jaundice,  peritonitis.  (5).  The  Urinary  Organs  : 
Nephritis,  vesical  catarrh,  haematuria.  (6).  Diseases  of  the  Integuments  and 
Bones  :  GSdema,  bed  sores,  gangrene,  noma  or  cancrum  oris,  "  hospital  gan- 
grene," buboes.  (7).  Other  Specific  Diseases  :  variola,  scarlet  fever,  diph- 
theria, erysipelas,  typhoid  fever  -------       284 

CHAPTER  XXX. 

Typhus — {continued). 
Varieties  of  Typhus  :  Inflammatory,  nervous  or  ataxic,  adynamic,  ataxo- 
adynamic  or  congestive,  Typhus  siderans,  Typhus  levissimus,  abortive,  catarrhal. 
Diagnosis:  from  relapsing  fever,  enteric  fever,  "jungle  fever,"  purpura, 
measles,  meningitis,  delirium  tremens,  asthenic  or  "typhoid"  pneumonia, 
uraemia — Prognosis  and  Mortality  :  Bad  signs  in  typhus  ;  death-rate  influ- 
enced by  age,  sex,  condition  of  life  and  habits,  season,  pregnancy,  fatigue,  priva- 
tion, late  treatment — Pathological  Lesions:  (1)  General;  (2)  Special, 
affecting  the  integumentary,  respiratory,  circulatory,  nervous  and  digestive 
systems  of  the  body — Pathology  of  the  "  Typhoid  State  "  .  .  .       293 

CHAPTER  XXXI. 

The  Treatment  of  Typhus. 

Prophylactic  and  Curative  Treatment  (or  "  Management  '').  Preven- 
tive Measures  :  Personal  cleanliness,  good  food  and  air-space,  ventilation. 
Management  :  hygienic  measures  adopted  at  Cork-street  Fever  Hospital, 
Dublin.  Nursing.  Medicinal  treatment  must  be  purely  symptomatic.  Water 
Treatment.  Quinine.  Alcoholic  Stimulants.  Food. — Treatment  of  Compli- 
cations and  Sequels  :  Pulmonary  congestion,  bronchitis,  paresis,  incontinence 
of  urine,  convulsions,  bedsores,  phlegmasia  and  thrombosis,  cedema.  Con- 
valescence :  costive  bowels.     Tonics.     Change  of  Air  ...       305 


XX11  CONTENTS. 

CHAPTER  XXXII. 

Relapsing,  Famine,  or  Spirillum  Fever. 

Page 
Nomenclature— Definition — iEtiology  (historical   sketch) — Mode  of   Preva- 
lence—Predisposing   Causes — Geographical    Distribution — Exciting    Cause — 
Bacteriology — Spirillum    Obermeieri — Inoculation    Experiments — One   Attack 
of  Relapsing  Fever  confers  no  immunity  against  a  second  -  -  .313 

CHAPTER  XXXIII. 

Clinical  Description  of  Relapsing  Fever. 

Sudden  onset. — High  Temperature Abrupt  crisis.  Intermission. — Re- 
lapse.— Low  mortality. — "  Bilious  Typhoid  "  (Griesinger). — "  Yellow  Fever  of 
the  British  Islands"  (Graves').— Heart  murmurs. — Stages  and  duration. — 
Temperature. — Complications  and  Sequelae  -  321 


CHAPTER  XXXIV. 

The  Diagnosis,  Prognosis,  Pathology  and  Treatment  op  Relapsing  Fever. 

Diagnosis  from  :  Typhus,  enteric  fever,  simple  continued  fever,  remittent 
fever  (''jungle  fever  "),  yellow  fever. ^Presence  of  the  spiroehsete  in  the  blood 
is  pathognomonic. — Prognosis  and  Mortality  :  Unfavourable  symptoms. 
Pathological  Anatomy. — Treatment  :  no  specific  for  Relapsing  Fever. 
Hygienic  and  Expectant  Treatment. — Nitre. — Treatment  of  symptoms  and 
complications. — "  Bilious  Typhoid  "  (Griesinger.) — Convalescence         -  -       328 

CHAPTER  XXXV. 

Enteric,  or  Typhoid,  Fever. 

General  Considerations. — Essential  difference  between  typhus  and  enteric 
fevers  not  recognised  in  the  past — reasons  for  this. — Evils  of  not  differentiating 
between  typhus  and  enteric  fevers. — Fundamental  distinctions. — Liebermeister's 
views       -  ...  .  .  .  .  .  .  .       335 


CHAPTER  XXXVI. 

Enteric  Fever  (continued). 

Nomenclature. — Synonyms. — Definition. — Literature  and  History. — 
Geographical  Distribution. — ^Etiology  :  Predisposing  causes  :  sex,  age,  defec- 
tive sewerage  and  drainage,  season,  temperature  and  moisture,  soil  and  under- 
ground water. — Immunity. — Exciting  cause. — Bacteriology  :  Bacillus  typho- 
sus (Eberth). — Supposed  spontaneous  origin  of  enteric  fever. — This  doctrine 
is  now  untenable. — Resting  spores. — Paths  of  Infection  :  currents  of  air, 
(Irinking  water,  milk,  meat. —Mode  of  invasion  ....       339 


CONTENTS.  XXIII 


CHAPTER  XXXVI L 

Clinical  Description  of  Enteric  Fever. 


Pago 


Stage  of  Incubation  or  Latent  Period— Stage  of  Invasion — Stage  of 
Glandular  Enlargement  —  Ulceration  and  Sloughing —  Amphibolic 
Stage — Stage  of  Lysis — Convalescence— Duration  of  the  Fever       -  -      363 

CHAPTER    XXXVIII. 

Analysis  of  the  Symptoms  of  Enteric   Fever. 

The  Physiognomy  of  Enteric  Fever. — The  Surface  :  lenticular  rose-spots, 
taches  bleudtres,  purpura  spots,  vibices,  sudamina,  accidental  or  adventitious 
rashes. — Desquamation. — The  Circulation. — The  Respiratory  System. — The 
Digestive  System  :  nausea,  vomiting,  meteorism  or  tympanites,  gargouillement, 
constipation,  diarrhoea,  intestinal  haemorrhage.  —  Spleen.  —  The  Urinary 
System. — The  Nervous  System  :  Liebermeister's  four  grades  of  nervous  dis- 
turbance.— Angel  Money's  observations  on  muscular  irritability.  — Organs  of 
Special  Sense  :  the  eye,  ear,  nose,  cutaneous  sensibility. — Emaciation  -      369 

CHAPTER  XXXIX. 

Relapse  in  Enteric  Fever. 

Relapse  is  a  rare  occurrence — Definition  of  True  Relapse — Relapses  not  to 
be  confounded  wich  Recrudescences — Clinical  Kecord  of  a  case  of  Relapse — 
Statistics  of  Occurrence  of  Relapse — Relapse  not  so  dangerous  as  the  first 
attack — ^Etiology  of  Relapse — Probable  influence  of  :  (1.)  Constipation  ;  (2.) 
Enlargement  of  the  Spleen  ..--.--       384 

CHAPTER  XL. 

Enteric  Fever  (continued'). 

temperature— complications  and  sequels. 

Temperature  important  in  diagnosis  and  prognosis. — Initial  or  Prodromal 
Stage  :  remittent  type. — Fastigium  :  continuous  type. — Amphibolic  Stage. — 
Defervescence:  remittent  type  with  "spiking." — Test  of  complete  recovery. — 
Remittent  type  of  pyrexia  in  young  children. — Moderate  pyrexia  in  old 
patients. — Apyrexial  or  Afebrile  Enteric  Fever.  Complications  and  Sequelae  : 
of  respiratory  tract,  the  circulation,  the  nervous  system,  organs  of  special  sense, 
digestive  tract,  the  urinary  organs,  female  organs  of  generation,  tissues,  integu- 
ments, and  bones ;  marasmus,  sudden  death. — Coexistence  of  other  specific 
diseases  „•--  .......       392 

CHAPTER  XLI. 

Varieties  of  Enteric  Fever. 

"  Typho-malarial  Fever." — Varieties  of  Enteric  Fever  :  Abortive  form 
(fievre  muqaeuse),  latent  form  (Typhus  ambulator ius),  "gastric,"  or  "bilious 
fever,"  spleno-typhoid,  acute  or  inflammatory  form,  infantile  remittent  fever 
("  worm  fever,"  or  "gastric  fever"),  senile  enteric  fever,  afebrile  or  apyrexial 
form         -  -  --•  -■-.-  -  -  -       405 


XXIV  CONTENTS. 

CHAPTER  XLIT. 

,  Enteric  Fever  (continued). 

Diagnosis— Prognosis  and  Mortality — Pathology. 


Page 


No  single  symptom  pathognomonic  of  Enteric  Fever.— Diagnosis  depends 
on  aetiology,  course  of  the  disease,  and  particularly  the  temperature. — 
Ehrlich's  Test.  Diseases  apt  to  be  confounded  with  Enteric  Fever  : 
Typhus,  relapsing  fever,  remittent  fever,  scarlatina,  smallpox,  pyaemia  and 
puerperal  fever,  gastro-intestinal  form  of  influenza,  tuberculosis,  trichuriasis, 
ulcerative  endocarditis,  acute  rheumatism,  &c.  Prognosis  and  Mortality  : 
Influence  of  age,  sex,  season,  station  in  life,  recent  residence  in  an  infected 
locality,  intensity  of  the  poison,  family  constitution,  personal  constitution 
and  habits,  previous  diseases.— Modes  of  Death:  Coma,  syncope,  asthenia 
or  anaemia,  hyperpyrexia  (rarely) — Fatal  Complications. — Pathological 
Anatomy  :  Specific  Lesions. — Non-Specific  Lesions  :  affecting  muscles,  heart, 
liver,  kidneys,  nerve-cells,  salivary  glands,  pancreas,  larynx        ...       408 

CHAPTER  XLIII. 

Intestinal  and  Splenic  Lesions  of  Enteric  Fever. 
Specific  Lesions  of  the  small  intestine,  mesenteric  glands,  spleen. — The 
stomach,  duodenum,  and  jejunum  usually  healthy  or  seat  of  non-specific  lesions. — 
Neighbourhood  of  Ileo-caecal  valve,  the  chief  seat  of  disease  in  both  ileum  and 
ceecum. — "Enterica  sine  enterilide."—"  Infective  Granuloma"  (Hilton  Fagge). — 
The  Intestinal  Lesion  :  its  four  stages — (1.)  enlargement  and  infiltration  ; 
(2.)  softening  and  ulceration;  (3.)  "typhoid  ulcer;"  (4.)  cicatrisation. — 
Plaques  dures  et  molles  (Louis). — Plaques  reticulees  et  gaufries  (Chomel). — 
Characters  of  the  "Typhoid  ulcer."  —  "Atonic  ulcers."  —  "Shaven-beard" 
appearance  (I'etat  pointille).  —  Perforation  of  the  peritoneum. — Lesions  of 
the  Mesenteric  Glands. — Lesions  of  the  Spleen  :  Putrilage,  abscess  -       419 

CHAPTER  XLIV. 

The  Prophylaxis  of  Enteric  Fever. 

Measures  to  be  adopted  for  Checking  the  Development  of  the  Fever 
Poison  :  Efficient  drainage  system. —Improved  water-closets. — Drinking  water 
to  be  taken  direct  from  the  main. — Use  of  chemical  disinfectants. — Measures 
for  Preventing  the  Propagation  of  the  Fever  Poison  :  Disinfection  of 
excreta. — Treatment  of  bedding  and  body  linen. — Ventilation  of  sick  room. — 
Trace  origin  of  first  case  of  fever  in  each  outbreak  ....       430 

CHAPTER  XLV. 

Curative  Treatment  of  Enteric  Fever. 

No  Specific  for  Enteric  Fever. — Principles  of  Treatment  apply  equally  to 
this  fever  and  to  typhus.  Curative  Treatment  or  Management  :  Hygiene, 
Diet,  Stimulants,  Antiseptic  Drugs: — Iodide  of  Potassium,  calomel,  arsenic, 
antimony,  /3-naphthol,  salicylate  of  bismuth,  salicylate  of  magnesium,  carbolic 
acid,  the  sulphites,  turpentine,  free  chlorine,  quinine,  oil  of  eucalyptus,  camphor, 
creasote,  thymol,  napbthalin,  salol  -  -    -  -   -  -       435 


CONTENTS.  XXV 


CHAPTER  XLVI. 

Curative  Treatment  of  Enteric  Fever  (continued). 


Pago 


Antipyretic  Treatment  :  (1).  The  Water-treatment  (hydrotherapy,  or 
balneotherapy),  cold,  cool,  and  warm  baths;  immersion  treatment  (Dr.  James 
Barr) — Description  of  Apparatus. — (2).  Reduction  of  Temperature  by  means 
of  the  Ambient  Air  (de  Souza). — (3).  Antipyretic  Drugs  :  Quinine,  salicin, 
.salicylic  acid,  the  salicylates,  salol,  phenazone,  acetanilid,  kairin,  thallin,  digi 
talis,  veratria,  resorcin  or  thymic  acid  with  acetanilid. — Hilton  Fagge's 
Placebo   -.---.-.„.      450 

CHAPTER  XLVII. 

Curative  Treatment  of  Enterio  Fever  (continued). 

treatment  of  certain  complications  and  sequels. 

Strong  Decoction  of  Coffee  and  Caffe'in  in  Ataxia  and  Adynamia. — 
Inhalation  of  Oxygen  in  Broncho-pneumonia. — Prevention  of  Bedsores. — 
Treatment  of  Epistaxis. — Treatment  of  Intestinal  Symptoms,  Complica- 
tions and  Sequelae  :  Constipation,  diarrhoea,  tympanites  or  meteorism, 
vomiting,  abdominal  pain,  haemorrhage  from  the  bowels,  peritonitis,  perforation, 
medical  and  surgical  measures    -  -  -  -  -  -  -461 

CHAPTER    XLVIII. 

The  Curative  Treatment  of  Enteric  Fever  (concluded). 

management  in  convalescence. 

Unwonted  exertion,  exposure  to  cold,  indiscretion  in  diet  are  all  to  be 
avoided. — Treatment  of  ;  Constipation,  atonic  diarrhoea. — Reduce  stimulants 
day  by  day. — Solid  Food  :  anecdote  narrated  by  Dr.  Stokes. — Rules  for  gi  vino- 
Solid  Food  :  Fish,  boiled  or  broiled — not  fried. — Dietaries  recommended  by 
Hilton  Fagge,  Murchison,  von  Ziemssen,  Niemeyer,  F.  Woodbury,  Hutchinson, 
Lauder  Brunton. — Medicines  in  Convalescence. — Change  of  Air. — Pro- 
longed Rest      ------...      475 

CHAPTER  XLIX. 

Infection  and  Immunity. 
Klemperer  and  Klemperer's  researches  on  Infection  and  Immunity. — Case 
of   acute  fibrinous   pneumonia. — Pneumotoxins    and    anti-pneumotoxins. — Dr. 
A.  C.  Abbott's  conclusions         .......      432 


PART  I. 


INTRODUCTION 


ERRATA. 

Page  25 — Line  7  from  bottom,  for  "fastidium  "  read  "fastigium." 

Page  42 — Line  4  from  top,  for  "minute  "  read  "second." 

Page  202 — Line  7  from  top,  for  "  not"  read  "now." 

Pages  320  and  324 — For  "  Moschutkovsky  "  read  "  Motschutkovsky. 

Page  326— Line  4  from  top,  for  "Plate  VI."  read  "Plate  VII." 


TEXT-BOOK 


EEUPTIVE  AND  CONTINUED  FEVERS. 


PART    I.— INTRODUCTION. 


CHAPTER  I. 
The  Intimate  Nature  of  Fever. 

Meaning  of  the  terras  "Fever"  and  "Pyrexia." — Pyrexia,  or  "  Feverish - 
ness,"  is  either  primary  (idiopathic,  specific,  or  essential  Fever)  or  secondary 
(symptomatic,  non-specific,  or  non-essential  Fever). — Definitions  of  Fever. — 
Theory  of  Animal  Heat. — The  "Thermal  Apparatus"  (Maclagan). — The 
"  Thermal  Nervous  System "  (Donald  Macalister). — The  Neurotic  and 
Metabolic  Theories  of  Fever. —  Cantani's  views  as  to  the  nature  and  use  of  the 
Fever  Process. — "Das  Heil-Fieber." — The  Pathology  of  the  Infective  or 
Specific  Fevers. — The  Essential  Phenomena  of  Fever. — Why  does  the  Fever 
Patient  waste  ? — Why  is  he  thirsty  ? — How  may  water  be  supplied  to  the 
Fever  Patient  ? — The  therapeutical  uses  of  water. 

The  word  Fever  means  literally  "  a  burning."  It  is  derived 
from  the  Latin  Febris  (Gk.  TrvpeTOs),  and  in  kindred  forms  appears 
in  the  chief  modern  European  tongues.  Thus,  we  have  lajievre  in 
French ;  das  Fieber,  in  German ;  la  febbre,  in  Italian  ;  la  Jiebre,  in 
Spanish  ;  Feber,  in  both  Swedish  and  Norwegian  or  Danish.  The 
Spanish  Calentura  expresses  the  same  idea.8. 

The  appropriateness  of  the  term  is  apparent  when  we  reflect  that 
the  essential  fact  in  fever  is  preternatural  body  heat.  This  is  in 
no  small  degree  due  to  increased  oxidation  (combustion)  of  nitro- 

a  "  Fieber  (irvpir6s  =  fever),  febris  eigentlich  ferbris  von  fervere  heiss  sein  ; 
appellamus  a  f>rvore  febrin  (Varro)." — Real-Encyclopadie  der  Gesammten 
JJeilkunde.  Siebenter  Band.  Wien  und  Leipzig  :  Urban  und  Schwarzenberg. 
1886.     S.  171. 

B 


2,  THE    INTIMATE    NATURE    OF   FEVER. 

genous  and  carbonaceous  substances  furnished  to  the  blood  by  the 
tissues,  but  mainly  by  the  food.a 

To  the  feverish  state,  the  term  Pyrexia,  or  Feverishness,  is 
applied.  Pyrexia  is  not  a  classical  Greek  word,  but  is  connected 
with,  and  derived  from,  the  future  indicative  tense  of  the  verb 
7rvpi(T(T(i)  (fut.  7rvpei;(o),  to  be  in  a  state  of  7rvp6To<i,  or  to  be 
feverish. 

Pyrexia,  or  "  feverishness,"  is  either  symptomatic  or  idiopathic. 

Symptomatic  fever  means  the  high  temperature  and  general 
constitutional  disturbances — such  as  shivering,  headache,  loss  of 
appetite,  nausea,  vomiting,  constipation  or  diarrhoea,  thirst,  pros- 
tration, sleeplessness,  and  so  on — which  accompanv  and  depend  on 
local  inflammations:  for  example,  abscess,  synovitis,  ophthalmia, 
peritonitis,  or  pleurisy.  This  form  of  fever  is,  accordingly,  often 
described  as  secondary,  or  accidental,  fever. 

Idiopathic  fever,  on  the  contrary,  means  the  high  temperature 
and  general  constitutional  disturbances  which,  although  occasion- 
ally complicated  with  local  inflammations — as,  for  example,  the 
enteritis  of  typhoid  fever,  the  sore  throat  of  scarlatina,  the  derma- 
titis of  smallpox — are  independent  of  them,  and  result  from  the 
absorption  from  without  of  some  poison,  which  under  favouring 
circumstances  multiplies  in  the  system,  or  from  the  action  on  the 
nervous  centres  of  a  poison  inbred  in  the  body — what  Murchison 
calls  a  "  non-specific  cause." 

As  in  this  case  the  morbid  phenomena  follow  in  the  train  of  the 
fever,  which  results  from  a  specific  cause,  idiopathic  fever  is  called 
primary,  specific,  or  essential,  in  contradistinction  to  symptomatic 
fever,  which,  as  we  have  seen,  is  secondary,  of  non-specific  or 
accidental  origin. 

From  the  earliest  times  elevation  of  bodily  temperature  above 
normal  has  ever  been  regarded  as  the  cardinal  fact  in  fever.  Mur- 
chison says  that  "  the  abstract  definition  of  Fever  given  by  Hippo- 
crates, Galen,  and  Avicenna,  was  'Essentia  vero  febrium  est  — 
praeter  naturam  caliditas'  (H  irapa  (pvaiv  depjjLa<Tia)."h 

a  Murchison  :  A  Treatise  on  The  Continued  Fevers  of  Great  Britain,     Third 
Edition.     Page  14.     London  :  Longmans,  Green,  &  Co.     1884. 
h  Loc.  cit,  page  14. 


THE    INTIMATE   NATURE   OF   FEVER.  3 

"Fever,"  wrote  Yirchow,a  the  Father  of  Modern  Pathology, 
"consists  essentially  in  elevation  of  temperature,  which  must  arise 
in  an  increased  tissue- change,  and  have  its  immediate  cause  in 
alterations  of  the  nervous  system." 

To  the  same  effect  Traubeb  declares  that  "  Fever  consists  essen- 
tially in  an  increased  temperature  of  the  blood  ;  "  and  Samuel  says  : — 
"By  fever  we  understand  an  elevation  of  temperature,  which  is 
evoked  through  lesion  of  the  Heat-centres." c  Again,  in  1887, 
Dr.  Donald  Macalisterd  held  that  "the  essential  fact  in  Fever, 
the  condition  which  is  always  present,  is  disorder  of  the  body-heat." 
And,  in  the  same  year,  the  late  Dr.  Austin  Flinte  wrote : — "  Fever 
is  a  condition  of  excessive  production  of  heat,  involving  defective 
nutrition  or  inanition,  an  excessive  production  and  discharge  of 
nitrogenised  excrementitious  matters  and  carbonic  acid,  with  waste 
and  degeneration  of  the  tissues,  and  partial  or  complete  suppression 
of  the  production  and  discharge  of  water."  Liebermeisterf  defines 
fever  "  as  a  symptom-group,  at  the  foundation  of  which  is  an 
elevation  of  the  temperature  of  the  body  produced  by  a  morbid 
general  increase  of  metamorphosis" — as  Dr.  Donald  Macalister 
graphically  says,  the  organism  during  the  febrile  process  is  like  "  a 
candle  burning  at  both  ends."  Lastly,  the  late  Dr.  Hilton  Fagge,8 
following  Liebermeister,  observed  that  "Pyrexia  consists  in  a 
change  in  the  normal  function  of  heat-regulation,  by  which  the 
production  of  heat  and  its  loss  are  so  balanced  as  to  create  and 
maintain,  while  the  pyrexia  lasts,  a  higher  temperature  instead 
of    the   normal    temperature.       One    might    imagine,"    he    adds 

a  Handbuch  der  speciellen  Pathologie  und  Therapeutic  Band  I.  Das  Fieber. 
Erlangen.     1854. 

b  Ueber  Krisen  und  kritische  Tage.     Berlin.     1 85  \ 

c  "Unter  Fieber  versteht  man  eine  Tempsraturerhohung,  welche  durch 
Erkrankung  der  Warme-centren  hervorgerufen  ist."  —  Real-Encyclopadie  der 
gesammten  Heilkunde.    Art.  "Fieber." 

d  The  Nature  of  Fever.     London:  Macmillan  &  Co.     1887. 

e  Fever :  its  Cause,  Mechanism,  and  Rational  Treatment.  Medical  News, 
Saturday,  September  10,  1887. 

f  Cf.  Handb.  der  Pathol,  und  Therap.  des  Fiebers.     1875. 

e  Principles  and  Practice  of  Medicine.  London  :  J.  &  A.  Churchill.  1886. 
Vol.  I.,  page  40. 


4  THE    INTIMATE   NATURE   OF   FEVER, 

theoretically,  "  the  index  of  the  regulating  machinery  to  be  shifted 
upwards,  so  that  it  is  set— not  at  98-4° — but  at  101°,  102°,  1039j 
or  even  a  still  higher  point." 

And  yet  there  exists  no  absolutely  pathognomonic  symptom 
for  fever.  Even  that  which  is  most  constantly  present,  the  eleva- 
tion of  temperature,  may  show  itself  without  fever ;  it  may,  on  the 
other  hand,  be  wanting  notwithstanding  the  fever.** 

To  the  right  understanding  of  the  intimate  nature  of  Fever,  a 
knowledge  of  the  Theory  of  Animal  Heat  is  indispensable.  It  is 
now  sufficiently  well  made  out  that  the  natural  heat  of  the  body  is 
due  to  both  vital  and  chemical  processes,  duly  controlled  by  the 
nervous  centres. 

The  physiological  facts  which  have  to  be  kept  before  us  in  con^ 
sidering  the  theory  of  Fever  are  well  and  clearly  described  by  Dr. 
T.  J.  Maclaganb  as  follow: — (1.)  Two  main  processes  embraced 
under  the  general  term  metabolism  (German,  Stoffwechsel),  are 
constantly  going  on  in  the  system — tissue  formation  (that  is, 
repair,  or  anabolism)  and  tissue  disintegration  (that  is,  waste, 
retrograde  metamorphosis,  or  katabolism).  (2.)  During  tissue 
disintegration  various  products  destined  for  elimination  are  formed — 
the  principal  of  these  are  urea,  carbonic  acid,  and  heat.  (3.)  Urea, 
is  eliminated  chiefly  by  the  kidneys,  carbonic  acid  chiefly  by  the 
lungs,  and  heat  chiefly  by  the  skin.  (4.)  In  the  case  of  each,  pro- 
duction and  elimination  are  so  well  balanced  that  no  accumulation 
takes  place  in  the  system.  (5.)  In  the  case  of  heat,  this  balance 
is  so  well  maintained  that  the  mean  normal  temperature  is  always, 
the  same  (98"4°  F.).  (6.)  The  various  processes  here  indicated  are 
presided  over  by  the  nervous  centres,  and  it  is  by  the  regulating 
power  of  these  centres  that  the  normal  balance  is  maintained. 

In  fever  this  whole  process  is  disturbed ;  there  is  increased  for- 
mation of  urea  and  carbonic  acid,  and  the  temperature  rises  above 

a  "  Es  giebt  kein  fiir  das  Fieber  absolut  pathognomoniBehes  Symptom.  Das 
constan teste  selbst,  die  Temperaturerhohung.kann  vorhanden  sein  okne  Fieber, 
es  kann  fehlen  trotz  des  Fiebers." — Samuel.  Art.  Fieber,  in  the  Real-Enrydo- 
padie  der  gesammten  Hedhunde.  Wien  und  Leipzig  :  Urban  und  Schwarzenbefg. 
.  b  Fever :  a  Clinical  Study.  By  T.  J  Maclagan,  M.D.  London:  J.  &  A. 
Churchill.     1888.     Page  2.  ,    .  .... 


.  I 

THE  INTIMATE  NATURE  OF  FEVER.  5 

98"4°  F.  "  The  preternatural  heat  of  fever,"  says  Murchison,  "  is 
the  result  of  vital  and  chemical  action  exalted  above  the  standard 
of  health,  assisted,  perhaps,  by  a  disturbance  of  the  processes  by 
which  heat  is  carried  away." 

The  parts  which  go  to  form  the  Thermal  Apparatus  are,  accord- 
ing to  Dr.  Maclagan  : — 

(1.)  The    tissues— and    particularly    the    muscles — in    which 

heat  is  formed. 
(2.)  The  surface  from  which  heat  is  eliminated — about  80  per 
cent,  normally  escaping  by  the  skin,  and  less  than  20 
per  cent,  by  the  lungs. 
(3.)  A  central  controlling  power  in  the  nervous  centres. 
(4.)  Nerves  connecting  this  with  the  heat-forming  parts  of  body. 
(5.)  Nerves  connecting  the  heat-centre  with  the  heat-elimin- 
ating surface. 
Dr.  Donald  Macalister  describes  the  Thermal  Nervous  System 
as  consisting  of  three  parts  : — 

(1)  The  Heat-adjusting  Mechanism  (ThermOtaxis). 

(2)  The  Heat-producing  Mechanism  (Thermogenesis). 
(8)  The  Heat-discharging  Mechanism  (Thermolysis). 

Disorder  of  the  first  implies  irregularity  of  temperature  only ; 
disorder  of  the  first  and  second  implies,  in  general,  heightened 
temperature  and  increased  body-heat — that  is,  ordinary  fever;  dis- 
order of  the  first,  second,  and  third  implies,  in  general,  hyperpyrexia 
(or  excessive  fever),  dangerous  increase  of  heat,  and  steadily  rising 
temperature. 

In  the  ascending  scale  of  evolution  in  the  Animal  Kingdom,  we 
seem  to  rise  from  the  thermolytie  to  the  thermogenic,  and  thence  to 
the  thermotaxic  nervous  system.  Cold-blooded  animals  possess  a 
thermolytie  mechanism — a  nervous  mechanism  which  controls  the 
vessels  and  the  breathing.  We  cannot  easily  throw  a  frog  into  an 
enduring  fever.  In  young  mammals,  the  thermogenic  system  is 
developed  before  the  thermotaxic — hence  a  slight  cause  sends  an 
infant  into  a  "high  fever"— a  little  restores  it  again.  As  the 
child  grows,  the  thermotaxic  mechanism  is  evolvedrand  its  tem- 
perature becomes  stable. 


6  THE  INTIMATE  NATURE  OF  FEVER. 

Dr.  Macalister  looks  upon  "Fever"  as  a  "dissolution" — a 
relaxation  of  control  from  above  downwards.  Thermotaxis  is  the 
first  part  of  the  mechanism  to  be  disturbed  and  overthrown.  Ther- 
mogenesis  then  becomes  more  and  more  excessive,  and,  lastly,  the 
thermolytic  mechanism  fails  to  act. 

In  recovery  from  a  typical  febrile  attack,  the  thermolytic 
mechanism  is  first  waked  to  adequacy,  and  the  result  is  a  critical 
sweat,  relaxation  of  the  vessels  of  the  skin,  and  a  sudden  fall  of 
surface  temperature.  Next,  tliermogenesis  becomes  less  and  less 
excessive ;  and,  lastly,  thermotaxis — the  first  to  be  disturbed  and 
overthrown — is  at  length  restored,  the  patient's  temperature  becom- 
ing more  and  more  stable. 

According  to  this  theory,  Fever  or  Pyrexia  depends  on  impaired 
thermotaxis,  exalted  tliermogenesis,  and  more  or  less  complete 
failure  of  thermolysis. 

In  other  words,  rise  of  temperature  above  normal  is  due  to — 
a.  Impairment  of  that  inhibitory  force  by  which  the  heat- 
producing  process  is  kept  within   normal  physiological 
bounds — that  is,  impaired  thermotaxis  ; 
yS.  Increased  activity  of  the  process  by  which  heat  is  naturally 
formed — that  is,  exalted  therm ogenesis. 

These  are  the  neurotic  and  metabolic  theories,  respectively,  of 
fever.  They  are  not  antagonistic,  but  each,  while  complete  in 
itself,  supplements  the  other. 

"  If  the  heat-centres  alone  are  diseased,"  writes  Samuel,a  "  the 
question  is  one  only  of  a  simple,  pure,  uncomplicated  fever  (febris 
simplex  pura).  If  through  the  exciting  cause  other  nervous  centres 
are  simultaneously  affected  with  the  heat-centres,  then  a  complex, 
mixed  fever  (febris  complicuta,  febris  mixta)  arises — in  this  case 
from  its  most  frequent  cause,  usually  designated  as  Infective  Fever 
(Inf ectionsfieber ) ." 

Professor  Arnaldo  Cantani,b  of  Naples,  is  not  satisfied  with  the 

a  Loc.  cit. 

b  Ueber  Antipyrese.    Transactions  of  the  Tenth  International  Congress,  Berlin, 
1890.     Vol.  I.,  page  152.     Cf.     The  Medical  Chronicle,  October,  1890.     Man- 
hester. 


TIIE    INTIMATE    NATURE    OF    FEVER.  7 

theory  which  makes  the  whole  fever  process  depend  on  certain 
nerve-centres.  The  local  production  of  heat,  the  result  of  pro- 
cesses of  chemical  combustion,  forms  an  essential  factor.  The 
action  of  nerve-centres  may  produce  a  temporary  rise  of  tempera- 
ture, but  not  a  continuous  or  remittent  elevation.  Fever  must  be 
looked  upon  as  an  acute  alteration  of  organic  metabolism,  with 
increase  of  tissue  combustion,  and  consequently  also  of  heat  and 
consumption  of  body.  Fever  is  a  general  or  essential,  and — to  a 
certain  degree — beneficial  reaction  of  the  organism  to  changes  in 
metabolism  and  in  the  blood,  produced  by  the  causative  agent 
of  the  disease.  This  reaction  is  necessary  to  bring  about  cure  in 
acute  disease.  Fever,  therefore,  may  be  useful  as  long  as  the 
consumption  of  tissue  does  not  give  rise  to  exhaustion,  and  the 
cardiac  muscle  does  not  suffer,  or  the  nervous  system  is  not 
threatened  by  hyperpyrexia.  Thus  the  temperature  alone  is  not  a 
measure  of  the  gravity  of  the  disease — a  moderate  degree  of  fever 
may  be  due  to  a  want  of  reactive  power  on  the  part  of  the 
organism,  a  high  degree  to  the  energy  with  which  the  organism 
defends  itself  against  the  invasion  of  the  disease.  Pyrexia  may 
thus  actually  be  of  use — (1)  by  diminishing  the  vitality  or  virulence 
of  the  living  causes  of  disease,  and  by  raising  the  temperature  of 
the  tissues  and  of  the  blood ;  (2)  by  increasing  the  power  of 
resistance  of  (he  tissue  elements  in  their  phagocytic  activity ;  (3) 
by  altering  the  nutritive  soil  in  the  tissues  and  rendering  it  less 
favourable  for  the  growth  and  development  of  the  germ  of  disease — 
in  fact,  by  sterilising  the  body.  At  the  close  of  his  able  Address 
Cantani  uses  these  remarkable  words : — "  Das  Fieber,  das  in  so 
vielen  Krankheiten  der  beste  Verbiindete  des  Arztes  ist "  ("  The 
fever,  which  in  so  many  diseases  is  the  best  ally  of  the  physi- 
cian "),  and  he  quotes  Boerhaave's  question  and  answer — "  Quid 
est  febris  ?  Est  naturae  irritatae  conamen  ad  expellendum  stimulum 
inconsuetum,"  as  well  as  Borsieri's  words — "  Quos  interdum  morbos 
remedia  non  curant,  febris  curat." 

Viewing  the   fever-process   in   this  light,  German  writers  now 
often  speak  of  what  they  call  "  Das  Heil-Fieber." 


8"  THE  INTIMATE  NATURE  OF  FEVER. 

The  Pathology  of  the  infective  or  specific  Fevers  may  be  thus< 
described  in  general  terms  :— 

1.  A  specific  poison,  called  the  "virus"  or  "contagium,"  enters 
the  blood. 

2.  This  poison  affects  the  nervous  system,  by  altering  its  blood- 
supply  both  in  quantity  and  in  quality,  and  disturbs  its  heat- 
producing,  regulating,  and  discharging  functions. 

3.  There  is  increased  tissue  change,  while  little  fresh  material 
is  assimilated  to  compensate  for  the  loss.  The  results  are — rise  of 
temperature,  muscular  prostration,  loss  of  weight. 

4.  Rapid  action  of  the  heart  results  from  nerve  paralysis  affect- 
ing the  pneumogastric  and  cardiac  ganglia,  as  well  as  from  the 
irritation  of  poisoned  blood.  A  pulse-rate  of  70  beats  per  minute 
represents  100,800  beats  of  the  heart  in  every  24  hours,  but  the 
fever-pulse  of  120  per  minute  represents  172,800  beats  in  every 
24  hours.    This  rapid  heart  action  still  further  increases  tissue  waste. 

5.  Non-elimination  of  waste-products  (or  ''  ashes,"  as  Dr.  Lauder 
Bruntona  aptly  «alls  them)  results  from  impaired  functional  activity 
of  the  skin,  kidneys,  and  bowels,  and  this — together  with  the  cir- 
culation of  poisoned  over-heated  blood — i causes  the  so-called  nervous 
or  ataxic  symptoms  of  fever,  as  well  as  other  complications.      ... 

6.  A  time  comes  when  these  Waste-products,  and  the  fever-poison 
also,  are  eliminated  by  the  breath,  the  -skin,  the  bowels,  or  the 
kidneys ;  when  also  the  fever-poison  perishes  either  through  lack 
of  nutrient  material  in  the  tissues  of  the  patient's  body  or  in 
consequence  of  the  development  of  -some  chemical  toxic  principle 
by  the  specific  micro-organisms  which  are  themselves  believed  to 
be,  or  to  give  rise  to,  that  fever-poison.  When  all  this  takes  place, 
the  nervous  system  resumes  its  normal  functions,  undue  tissue 
waste  is  checked,  the  different  organs  and  tissues  recover  their 
wonted  activity,  and  the  patient  regains  his  health  and  strength. 
If  this  favourable  change  takes  place  quickly,  we  say  that  the 
fever  has  ended  by  crisis;  if  gradually  and  slowly,  we  speak  of 
resolution  of  the  fever  by  lysis. 

a  Address  in  Medicine  to  the  Brit.  Med.  Assoc.  1891.  Cf.  Brit.  Med' 
Journal,  Aug.  1,  1891,  page  229. 


THE    INTIMATE   NATURE    OF    FEVER.  9 

In  this  sketch  of  the  pathology  of  fever  in  the  abstract,  I  have 
closely  followed  Murchison's  aphorisms,  and  these  are  based  on 
physiological,  clinical,  and  pathological  considerations  which  cannot 
be  gainsaid. 

The  essejitial  phenomena  of  fever  are,  according  to  Maclagan — 

1.  Wasting  of  the  nitrogenous  tissues. 

2.  Increased  consumption  of  water. 

3.  Increased  elimination  of  urea. 

4.  Increased  rapidity  of  the  circulation. 

5.  Preternatural  body-heat  ("calor  praeter  naturam  " — Galen.) 
If  we  bear  these  phenomena  in  mind,  we  shall  be  in  a  position, 

with  Dr.  Maclagan,  to  answer  the  questions  :  "  Why  does  the  Fever 
Patient  waste  ? " — "  Why  is  he  thirsty  ?  "  We  have  already  hinted 
at  the  causal  relation  to  fever  in  which  certain  micro-organisms 
stand.  These  will  be  more  minutely  described  in  the  second 
chapter,  on  the  "  Intimate  Nature  of  Contagium."  Suffice  it  here 
to  state  that  these  micro-organisms,  or  microbes,  consist  largely  of 
protoplasm.  Tliey  are.  reproduced  in  vast  numbers  in  the  system 
during  the  course  of  the  disease  to  which  they  give  rise,  and  in 
their  growth  they  consume  a  large  quantity  of  nitrogen  and  of 
water. 

Voit  has  distinguished  between  the  fixed  or  organ-albumen, 
which  enters  into  the  composition  of  the  solid  tissues  and  changes, 
slowly,  and  the  circulating,  or  store-albumen,  which  is  contained  in 
the  blood  and  fluids  of  organs,  and  very  readily  undergoes  change. 
This  circulating  or  store-albumen  consists  of  two  parts — a  con- 
structive part,  destined  for  the  nutrition  and  building  up  of  the 
tissues,  and  a  retrogressive  part,  derived  from  tissue-waste  and 
destined  for  excretion.  The  former  is  converted  into  solid  nitro- 
genous tissue  ;  the  latter  is  converted  into  urea  in  the  urea-forming 
glands,  and  as  such  is  eliminated  chiefly  by  the  kidneys. 

The  constructive  store-albumen  is  the  som*ce  whence  the  "  con- 
tagium" would  by  preference  naturally  take  its  nitrogen,  and  so. 
the  tissues  are  "starved  "  in  fever— hence  the  wasting  of  fever. 

But  the  protoplasm  of  the  living  and  active  contagium  consists; 
mainly  of  water,  and  for  its  growth  a  large  consumption  of  water 


10         THE  INTIMATE  NATURE  OF  FEVER. 

is  required.  This  is  drawn  from  the  tissues,  and  at  the  same  time 
the  water  taken  in  by  the  patient  is  appropriated  by  the  contagium. 
Hence  the  dry  skin  and  the  parched  mucous  membranes  of  fever, 
as  well  as  the  inordinate  thirst  and  the  loss  of  appetite  complained 
of  by  the  patient,  the  scanty  urine,  and  the  constipation. 

The  thirst  of  fever  is  the  expression  of  a  real  want  in  the  system, 
it  is  a  craving  for  more  water.  Such  is  Maclagan's  theory — 
ingenious  indeed,  but  not  yet  capable  of  demonstration,  or  free 
from  difficulties. 

The  further  question  arises — How  may  water  be  supplied  to 
the  fever-patient  ?  A  long  personal  experience  has  convinced  me 
that  no  risk  to  the  patient  in  fever  arises  either  from  the  use  of 
cold  water  as  a  beverage,  or  from  frequent  ablutions,  such  as  are 
necessary  if  personal  cleanliness  is  to  be  maintained.  In  the  case 
of  young  children,  especially,  to  withhold  water  in  fever  is  down- 
right cruelty.  Taken  internally,  water  is  the  most  effectual  assuager 
of  consuming  thirst,  the  best  and  safest  diuretic,  diaphoretic, 
aperient  and  eliminative,  we  can  prescribe.  Its  administration  in 
moderate  quantities,  given  at  frequent  intervals,  often  allays  delirium 
and  induces  sleep.  Another  way  in  which  water  may  be  given  is 
in  the  form  of  ice,  sucking  fragments  of  which  is  most  grateful  to 
the  patient,  as  well  as  beneficial,  for  it  reduces  temperature,  relieves 
sore  throat,  and  allays  sickness  and  vomiting. 

There  can  be  no  doubt  also  that,  in  fever,  water  is  absorbed  by 
the  skin,  when  tepid  sponging  is  practised,  or  the  patient  is  placed 
in  a  warm,  tepid,  or  even  cold  bath. 

In  his  work  on  "Therapeutics,"*  Dr.  H.  C.  Wood,  Professor  of 
Materia  Medica  and  Therapeutics  in  the  University  of  Pennsyl- 
vania, speaks  highly  of  the  value  of  water  as  a  diuretic  in  certain 
diseases.  In  an  elaborate  series  of  experiments,  E.  Rouxb  found 
that  the  ingestion  of  large  quantities  of  water  greatly  increased  the 
flow  of  urine,  but  did  not  sensibly  affect  the  elimination  of  urea  or 
uric  acid,  although  that  of  the  chlorides  seemed  to  be  augmented. 

a  Therapeutics:  its  Principles  and  Practice.     By  H.  C.  Wood,  M.D.,  LL.D. 
Seventh  Edition.     London  :  Smith,  Elder  &  Co.     1888.     Page  706. 
b  Archives  Physiologiques.     1874.     Page  578. 


THE  INTIMATE  NATURE  OF  FEVER.  11 

In  a  paper  entitled  "  Einfluss  des  Wassers,"  communicated  to  tlie 
Zeitschrift  der  k.  k.  Gesellschaft  der  Aertze  zu  Wien  for  April,  1864 
(page  308),  Dr.  Bocker"1  arrived  at  the  following  conclusions :  — 

1.  That  water  increases  the  interstitial  metamorphosis  of  tissue 

and  consequent  loss  of  weight. 

2.  That  the  decomposed  tissue  is  excreted  partly  in  the  urine 

and  partly  in  the  solid  faeces. 

3.  That  the  water  formed  in  the  organism  by  the  change  of 

tissue  is  augmented,  as  well  as  the  nitrogenous  consti- 
tuents of  the  excretions. 

The  investigations  of  J.  Meyer  b  explain  these  discrepancies,  and 
show  how  water  may  be  of  use  in  various  diseases.  He  found  that 
at  times,  when  the  tissues  were  full  of  the  products  of  disintegration, 
the  effect  of  water  in  increasing  elimination  was  very  marked,  but 
that  upon  the  wasting  processes  of  the  body  the  water  exerted  no 
influence.  Having  quoted  these  opinions,  Dr.  Wood  goes  on  to 
say — "  It  would  seem,  therefore,  that  while  we  cannot  by  water 
produce  tissue-disintegration,  we  can  by  it  wash  out  the  retained  pro- 
ducts of  tissue-change" 

This  is  one  of  the  most  pressing  indications  of  treatment  in  fever, 
and  it  is  of  the  first  importance  to  the  physician  to  know  that  it  is 
safely  and  efficiently  fulfilled  by  the  internal  administration  of 
water. 

n  Brit,  and  Foreign  Med.-CMr.  Rev.     Vol.  XIV.,  page  394.     1854. 
b  Hoffmann  und  Schwalbe's  Jahresbericht.     1881.     Page  345. 


12 


CHAPTER  II. 
The  Intimate  Nature  of  Contagion. 

Communicable  arid  Non-communicable  Diseases. — The  "  Germ  Theory  of 
Disease." — Meanings  of  the  term  "  Contagion." — Zymotic  Diseases. — A  typical 
example  of  Fermentation.— Nageli's  Classification  of  the  decomposition-pro- 
ducing Fungi:  Moulds,  Yeasts,  Fission-fungi  (including  Bacteria). — Characters 
and  sub-divisions  of  the  Fission -fungi,  or  Schizomycetes. — Non-pathogenic 
Micro-organisms  or  Microbes  (Saprophytes).— ^Pathogenic  Micro-organisms 
or  Microbes  .( Parasites). — Division  of  the  latter  into — (1.)  Non-infectious,  but 
toxic,  organisms  ;  (2.)  Truly  infectious  organisms. — Toxins,  or  Ptoma'ins. — 
Crookshank's  Classification  of  Bacteria. — Aerobic  and  Non-aerobic  Micro- 
organisms ( Pasteur) :  their  food  and  drink. — JSporulation :  "Besting  Spores." — 
Explanation  of  supposed  spontaneous,  or  de  novo,  origin  of  Infectious  Fevers. — 
Specific,  infective  microbe,  virus,  or  contagium. — Seat  of  the  Development  of 
the  several  Contagia. — Inoculation. — "Contagious"  and  "Infectious"  Diseases. 

Diseases  may  be  roughly  divided  into  two  great  classes — communi- 
cable diseases,  or  those  capable  of  being  imparted  or  communicated 
from  one  living  being  to  another ;  and  non-communicable  diseases, 
or  those  not  capable  of  being  so  imparted  or  communicated.  Some  of 
the  former  class  are  interchangeable,  not  only  between  one  indivi- 
dual of  the  same  species  and  another,  but  also  between  animals 
and  men  or  between  men  and  animals.  Familiar  examples  are : 
hydrophobia,  malignant  pustule  (anthrax,  or  charbon),  glanders, 
tuberculosis,  smallpox,  and  others. 

On  the  threshold  of  our  investigations  into  the  intimate  nature 
of  contagion  we  are  brought  face  to  face  with  what  has  been  called 
the  "  Germ  Theory  of  Disease." 

The  word  "  Contagion  "  a  has  been  employed  in  two  very  different 
senses,  which  it  is  here  necessary  to  discriminate.  In  the  first 
place,  it  is  a  comprehensive  term  which  includes,  and  is  used  to 
express,  all  the  different  agencies  by  which  zymotic,  or — as  they 
are  now  generally  called — micro-parasitic,  diseases  are  known  to 

a  Lat.  Contagio  ;  or  in  the  poetical  form,  Contagium ;  from  cum,  and  tango, 
I  touch  (coittingo). 


THE    INTIMATE    NATURE    OF    CONTAGION.  13 

spread.  But  again  the  "  contagion,"  or  "  contagium,"  of  a  disease 
is  the  poisonous  principle,  or  virus,  which  when  introduced  into 
the  system  from  without,  hy  inoculation,  or  inhalation,  or  in  the  act 
of  swallowing,  is  capable — under  favourable  circumstances — of 
multiplying  itself  and  setting  up  the  phenomena  of  the  disease  in 
question.  It  is  to  be  noted  that  each  disease  has  its  own  peculiar 
or  special  poison  or  virus,  which  is  accordingly  called  "specific." 
In  recent  years  the  generic  term  "  infective  "  lias  been  applied  to 
any  form  of  disease  which  is  believed  to  be  due  to  a  specific  cause. 
The  word  exactly  represents  the  German  expression,  "  lnfections- 
krankheit." 

The  processes  of  typical  infective  diseases  in  the  human  body 
present  many  analogies  to  those  of  fermentation  in  an  organic 
liquid.  Hence  the  virus  or  contagium  is  often  called  the  "  ferment," 
or  "  leaven,"  or  "  zyme  "  (Gk.  £v/ai]),  and  the  resulting  diseases  are 
called  zymotic. 

The  analogy  will  become  very  apparent  if  Ave  quote  a  typical 
example  of  fermentation.  When  the  yeast  plant  (Saccharomyces, 
or  Torula  cerevisioe)  obtains  access  to  a  saccharine  fluid  and  the 
temperature  is  suitable,  the  cells  of  the  yeast  rapidly  multiply,  and 
after  a  certain  time — which  corresponds  with  the  period  of  incuba- 
tion in  an  infective  disease — changes  are  produced  in  the  saccharine 
liquid,  evidenced  by  the  formation  of  alcohol  and  carbonic  dioxide 
(C02),  which  eventually  render  it  incapable  of  being  further  acted 
upon  by  that  particular  ferment. 

According  to  the  now  generally  accepted  "  Germ  Theory,"  the 
contagia  of  the  so-called  Zymotic  Diseases  are  microscopic  living 
particles  probably  of  a  vegetable  nature,  which,  for  the  most  part, 
belong  to  the  class  of  micro-organisms  to  which  the  name  Schizo- 
mycetes,  or  Fission-fungi  (Germ.  Spaltpilze),  has  been  given  by 
Nageli.  That  investigator  divided  the  fungi  engaged  in  producing 
fermentation  and  decomposition  (or  putrefactive  fermentation) 
into — 

Hyphomycetes,  Mucorini,  or  "  Moulds"  (Germ.  Fadenpihe). 

Saccharomycetes,  or  "  Yeasts  "  (Germ.  Hefenpilze). 

Schizomycetes,  or  "  Fission-fungi "  (Germ.  Spaltpilze). 


14  THE    INTIMATE   NATURE    OF   CONTAGION"! 

To  the  class  of  the  "Fission-fungi,"  or  "Cleft-fungi"  (Schizo- 
mycetes*),  belong  the  Cocci,  Bacteria,  Leptotriches,  and  Clado- 
trich.es  (Zopf).  The  fission-fungi  do  not  contain  chlorophyll,  and 
are  composed  of  a  kind  of  protoplasm,  called  mycoprotein  by 
Nencki,  with  an  investing  membrane  chiefly  of  cellulose.  Many 
of  these  micro-organisms — or,  as  the  French  call  them,  microbes  b — 
exist  in  enormous  numbers  in  the  air,  water,  and  soil  in  every 
region  and  climate,  and  to  them,  in  conjunction  with  yeasts  and 
moulds,  the  fermentative  and  putrefactive  changes,  to  which  organic 
matter  is  liable,  are  due. 

Certain  of  these  micro-organisms  or  microbes  live  on  dead 
organic  matter  only,  and  are  not,  therefore,  concerned  in  the  direct 
production  of  disease.  These  are  called  Non-pathogenic  Microbes, 
or  Saprophytes.  c  Included  amongst  them  are  various  micrococci, 
bacilli,  &c. 

Others  of  these  micro-organisms  prey  either  on  living  organic 
matter  only,  or  on  both  living  and  dead  organic  matter.  These 
are  the  disease-producing,  or  Pathogenic  Microbes,  or  Parasites. d 
They,  also,  include  various  micrococci,  bacilli,  &c. 

As  true  parasitic  micro-organisms  do  not  exist  outside  the  living 
body,  we  are  not  at  present  in  a  position  to  study  them  by  means 
of  cultivations  in  artificial  media  such  as  gelatine,  Agar- Agar  (or 
Japanese  gelatine),  animal  broth,  and  so  on.  To  this  group  belong 
the  micro-organisms  of  smallpox,  cowpox,  whooping-cough,  measles, 
&c,  of  the  intimate  nature  of  which  we  at  present  of  necessity 
know  but  little.     These  microbes  are  called  "  Obligate  Parasites." 

Many  pathogenic  or  parasitic  organisms,  on  the  other  hand,  do 
possess  the  power  of  attacking  non-living  matter,  so  affording 
evidence  of  a  certain  amount  of  saprophytism.  Hence  we  are  able 
to  cultivate  these  outside  the  living  body  in  artificial  media.  This 
class  embraces  the  microbes  of  tubercle,  diphtheria,  anthrax,  erysi- 
pelas, tetanus,  and  so  on.    They  are  called  "  Facultative  Parasites." 

a  Gk.  <rx^Ca')  I  cleave  ;  pinys,  a  fungus,  or  mushroom. 
bGk.  fiiKpos.  small;  fSios,  life. 
cGk.  (jairp6s,  rotten;  <pvr6v,  a  plant. 

d  Gk.  napdaiTos,  one  tvho  eats  beside  or  at  the  table  of  another  ;  one  who  lives 
at  another  s  expense. 


THE   INTIMATE   NATURE   OF   CONTAGION.  15 

Another  classification  of  the  pathogenic  or  parasitic  microbes  is 
into — 

(1)  Non-infectious,  but  toxic,  organisms;  and 

(2)  Truly  infectious  organisms. 

The  latter,  which  include  the  microbes  of  some  of  the  specific 
fevers,  are  found  to  pervade  the  blood  and  every  organ  of  the  body. 
The  former,  of  which  the  microbes  of  diphtheria  and  tetanus  are 
typical  examples,  act  on  the  organism  through  certain  poisonous 
principles  which  they  produce  during  their  lifetime  or  by  their  death. 
These  poisonous  principles  are  of  an  alkaloidal  nature,  and  are 
called  Toxins  or  Ptomains,a 

Dr.  Edgar  M.  Ciookshank,  in  his  Manual  of  Bacteriology]0  says  : 
"  Bacteria  may  be  grouped  together  according  to  the  changes 
produced  in  the  media  in  which  they  grow.  Thus  we  have 
pigment-forming,  fermentative,  putrefactive,  and  pathogenic 
bacteria." 

The  pigment-forming,  or  chromogenic  bacteria,  produce  various 
colour-stuffs.  Thus,  the  Micrococcus  prodigiosus  forms  a  blood- 
red  growth  in  bread,  potato,  and  other  media.  Bacillus  violaceus 
produces  a  violet  pigment,  and  B.  pyocyaneus  a  delicate  green. 
The  magenta  micrococcus  forms  a  brilliant  magenta  growth,  with 
a  metallic  lustre.  In  this  species  the  pigment  is  retained  within 
the  cells.  The  surface  of  sterilised  potato  is  a  very  favourable 
medium  for  the  cultivation  of  these  most  interesting  chromogenic 
m  icro-organisms. 

The  fermentative  bacteria  are  also  termed  zymogenic,  the  putre- 
factive are  saprogenic,  and  the  pathogenic  are  the  disease-producing 
microbes. 

Some  micro-organisms  require  free  access  of  oxygen  for  their 
growth,  and  so  they  received  the  name  of  aerobic  c  from  Pasteur. 
Others  grow  and  flourish  without  free  oxygen,  and  are  anaerobic  d 
(Pasteur).      All   require  for  their  growth   carbon,   nitrogen,   and 

a  Gk.  to  t6£ikov,  arrow  poison  ;  irTwfj.a  (from  iriirrw,  I  fall),  a  fallen,  i.e.,  a 
dead  body. 

b  London  :  H.  K  Lewis.     Second  Edition.     1887.     Pages  141  and  142. 

c  Gk.  a-fip,  air;  P'tos,  life. 

d  Gk.  av-,  the  negative  prefix  in  Greek. 


16  THE   INTIMATE   NATURE   OF    CONTAGION. 

water,  as  well  as  a  certain  temperature,  which  varies  from  18°  C. 
to  40°  C.  (64-4°  F.  to  104°  F.)  in  the  case  of  the  pathogenic 
microbes.  While  all  these  microbes  are  capable  of  disintegrating 
organic  combinations  containing  nitrogen,  they,  in  their  turn,  help 
to  produce  certain  definite  chemical  products  for  definite  species. 

These  microbes,  whether  pathogenic  or  non-pathogenic,  whether 
parasitic  or  saprophytic,  grow  and  multiply  enormously ;  but  they 
are  very  short-lived,  and  are  easily  destroyed,  perishing  in  vast 
numbers,  often  in  consequence  of  the  chemical  compounds  (toxins 
or  ptomams)  to  which  they  themselves  give  rise. 

How,  then,  are  the  several  species  preserved  from  extinction? 
By  sporulation.  Spores,  the  immature  forms  of  the  adult  species, 
can  resist  extremes  of  temperature  and  of  desiccation,  or  drying, 
which  are  destructive  to  the  fully-developed  organisms.  So  reten- 
tive of  life  are  these  spores  that  they  are  called  "Resting  Spores." 
They  represent  seeds  capable  of  retaining  and  germinating  into 
microbes  even  after  what  would  appear  the  most  damaging  in- 
fluences— such  as  long  lapse  of  time,  drying,  extremes  of  heat  or 
cold,  chemical  reagents,  and  the  like. 

.  These  spores  are  generally  spherical  when  immature,  oval  when 
fully  developed.  They  are  of  a  glistening  appearance,  and  take 
the  ordinary  dyes  with  difficulty,  or  not  at  all. 

This  spore-formation  closes  the  cycle  of  the  life-history  of  the 
microbe.  The  theory  of  sporulation  explains  those  puzzling  in- 
stances in  which  infectious  diseases  have  been  supposed  to  have 
arisen  independently  of  a  previous  case — that  is,  spontaneously,  or 
de  novo. 

The  pathogenic  organism  of  each  of  the  infective  diseases  is 
specific—that  is,  it  is  peculiar  to  the  particular  disease,  standing 
in  a  causal  relation  to  it  and  to  no  other  malady.  Thus,  the 
microbe  of  scarlet  fever  gives  rise  to  scarlet  fever  and  to  it  alone  ; 
that  of  smallpox,  to  smallpox  and  to  it  alone — "the  seed,  as  a 
gardener  would  say,  comes  up  true  "  (Dr.  Robert  Liveing).  Hence 
these  maladies  are  spoken  of  as  "  specific  "  or  "  essential  febrile 
diseases."     This  is  ah  established  clinical  and  pathological  fact. 

In  each  special,  or  specific,  disease  the   virus,  or  contagium, 


THE   INTIMATE    NATURE   OF   CONTAGION.  17 

multiplies  chiefly  in  those  tissues — the  mucous  and  epithelial — 
which  are  more  especially  subject  to  its  action,  and  the  infection 
is  cast  off  from  the  body  in  large  part  with  the  excretions  or 
secretions  of  those  tissues.  For  example,  the  poison  or  virus  of 
typhoid  fever  passes  out  of  the  system  chiefly  in  the  evacuations 
from  the  bowels ;  that  of  scarlet  fever  passes  off  chiefly  by  or  from  the 
skin.  In  the  former  case  the  contagium  is  propagated,  not  so  much 
through  the  air  as  by  means  of  water,  milk,  or  other  food  to  which 
the  evacuations  have  gained  access.  In  the  latter  case  the  contagium 
may  be  dormant  in  the  clothes  or  furniture  of  the  sick  room  for 
long  periods,  or  it  may  be  carried  through  the  air  from  the  diseased 
to  the  healthy. 

In  the  case  of  some  of  the  infective  diseases  the  contagium  does 
not  seem  to  be  capable  of  retaining  an  independent  existence  outside 
the  animal  body — the  infective  microbe  is  solely  parasitic,  not  in  any 
sense  saprophytic.  In  these  maladies  the  infection  (or  contagium) 
is  conveyed  by  direct  contact — that  is,  by  inoculation  from  the 
diseased  body  into  the  tissues  of  the  healthy  :  examples  of  this 
are — syphilis,  gonorrhoea,  hydrophobia,  and  glanders. 

These  infective  diseases,  then,  are  sometimes  further  artificially 
classified  as  contagious,  or  those  transmitted  only  by  direct  in- 
oculation or  immediate  contact,  and  infectious,  or  those  transmitted 
through  the  air  or  by  other  carriers  of  infection  (fomitesa),  such  as 
wearing  apparel,  furniture,  bedclothes,  dust,  skin-particles,  fasces 
(as  in  enteric  fever  and  cholera),  and  so  on.  It  will  be  necessary 
to  revert  to  this  subject  in  the  next  chapter. 

a  Lat.  forties,  formtis,  touch-wood,  tinder  (i i om  foveo,  I  warm). 


18 


CHAPTER  III. 

MlCEO-PARASITIC    DISEASES. 

Substitution  of  this  term  for  "Zymotic  Diseases." — "Infective  Diseases." — 
Liebermeister's  Classification:  1,  Miasmatic;  2,  Miasmatic-Contagious;  3, 
Parasitic-Contagious  (Infectious  or  Contagious). — Endemic,  Epidemic,  Sporadic, 
and  Pandemic  :  definition  of  these  terms. — Theories  of  Immunity. — Natural 
and  Acquired  Immunity.— Metschnikoff's  theory  of  Phagocytosis. — Phago- 
cytes (Germ.  "  Fresszellen  "). — "Micro-Strife  "  (A.  Wynter  Blyth). — Acquired 
Immunity. — Classification  of  Micro-parasitic  Febrile  Diseases  :  1,  The  Eruptive 
Fevers  or  Exanthemata  ;  2,  The  Continued  Fevers ;  3,  The  Intermittent 
Fevers.  — Cyclical  course  of  the  Specific  or  Essential  Fevers:  1,  Incubation; 
2,  Invasion;  3,  Eruption;  4,  Defervescence;  5,  Desquamation  ;  6,  Convales- 
cence.— Quarantine. — Isolation. — Influence  of  the  Micro -parasitic  Diseases  on 
each  other. 

It  was  shown  in  the  preceding  chapter  that  each  of  the  so-called 
Zymotic  Diseases  has  its  own  peculiar  disease-producing  or  patho- 
genic micro-organism,  which  is  properly  called  a  "  parasite." 
Hence  the  term  "  Micro-parasitic  Diseases  "  is  now  being  adopted 
in  place  of  the  older  expression  ''  Zymotic  Diseases."  It  was 
further  shown  that  each  of  these  affections  has  its  own  peculiar  or 
special  poison  or  virus,  so  that  they  are  called  "  Infective  Diseases  " 
(Germ.  Infections-krankheiten).  The  fever  which  attends  them  is 
in  a  sense  not  symptomatic:  it  is  primary,  or  idiopathic,  and  thus 
we  come  to  speak  of  them  as  the  "  Essential "  or  "  Specific  Fevers." 
Probably  the  best  classification  of  these  infective,  or  micro- 
parasitic,  diseases,  would  be  that  adopted  by  the  German  School, 
as  represented  by  Liebermeister  : — 

(1)  Miasmatic. 

(2)  Miasmatic-Contagious. 

(3)  Parasitic-Contagious  ;  that  is,  Infectious  or  Contagious. 

1.  Miasmatic  Diseases  are  those  which  result  from  the  intro- 
duction of  a  specific  poison  into  the  body  from  without — the  poison 
being  developed  outside  of  the  body,  usually  in  marshy  or  swampy 
districts,  or  where  there  is  an  insufficiency  of  healthy  vegetation 
and  a  waterlogged  soil.     The  "morbific  agent"  is  almost  certainly 


MICRO-PARASITIC    DISEASES.  19 

microbic.a  It  is  usually  inhaled,  but  may  be  swallowed  with  food 
or  water  exposed  to  marsh  air.  It  is  incapable,  apparently,  of 
reproduction  in  the  animal  body,  it  is  not  propagated  by  an  infected 
person,  and  it  produces  in  the  system  solely  its  own  specific  effects — 
fever,  enlargement  of  the  spleen,  and  a  peculiar  cachexia.  This 
poison  of  miasmatic  diseases  is  technically  called  Malaria. 

Typical  miasmatic  diseases  are  "  Intermittent  Fever  "  or  "  Ague," 
in  which  periods  of  complete  apyrexia  or  freedom  from  fever  occur, 
and  "Remittent  Fever"  or  "Jungle  Fever,"  in  which  the  fever 
remits  indeed  from  time  to  time,  but  does  not  absolutely  disappear. 
Both  these  forms  of  disease  are  known  as  Malarial  or  Paludal 
Fevers  (Latin  :  Palus,  paludis,  a  swamp).  They  do  not  more  imme- 
diately concern  our  present  purpose. 

2.  Miasmatic-Contagious  Diseases  are  those  like  enteric  or 
typhoid  fever,  cholera,  and  perhaps  influenza,  which,  although 
spreading  through  human  intercourse,  are  thought  not  to  be 
communicable  directly  from  one  person  to  another.  This,  as 
Liebermeister  supposed,  is  in  consequence  of  the  inadequacy  of 
the  contagiurn  to  propagate  the  disease  without  undergoing  some 
further  change  outside  the  body  and  so  becoming  a  miasm. 

3.  Parasitic-Contagious  Diseases  are  those  which  are  capable  of 
being  transmitted  from  one  person  to  another,  or  from  one  animal 
to  another  of  either  the  same  or  another  species,  either  by  direct 
contact,  or  through  the  agency  of  air  or  water,  or  by  other  carriers 
of  infection,  technically  called  fomites.b  In  the  former  case,  the 
diseases  are  strictly  and  truly  contagious,  like  syphilis  or  hydro- 
phobia; in  the  latter  case  they  are  described  as  "common  infectious 
diseases,"  like  smallpox,  measles,  scarlet  fever,  typhus,  and  so  on. 

As  regards  their  manner  of  prevalence,  zymotic  or  micro-parasitic 
diseases  are  spoken  of  as  endemic,  epidemic,  or  sporadic.  To 
these  terms  we  may  add  a  fourth,  pandemic,  which  was  used  by 
Dr.  Robert  Lawson,  Inspector-General  of  Hospitals,  in  connection 
with  wide-spread  epidemics,  particularly  of  cholera. 

a  Klebs  and  Tommasi-Crudeli :  Bacillus  malaria.  And,  more  recently,  Celli 
and  Marchiafava  :  Plasmodium  malaria.  See  Fortschrilte  der  Medicin,  1883 
and  1885. 

b  See  footnote  on  page  17. 


20  MICRO-PARASITIC   DISEASES. 

1.  Endemic  Diseases*  are  those  which  arise  and  prevail  in  a 
given  country,  place,  or  neighbourhood,  under  conditions,  circum- 
stances, or  agencies,  peculiar  to  the  locality  in  question,  and  which 
favour  the  development  of  the  said  diseases.  For  examples,  we  may 
instance  among  miasmatic  diseases  intermittent  fever,  or  ague,  and 
remittent  fever,  or  jungle-fever ;  among  the  miasmatic-contagious 
diseases,  cholera  (in  the  Valley  of  the  Ganges),  enteric  fever,  and 
perhaps  influenza. 

2.  Epidemic  Diseases'3  are  those  which  prevail  among  a  people 
or  community  at  a  given  time,  and  are  produced  by  some  special 
cause  or  causes  not  naturally,  or  generally,  present  in  the  affected 
locality.  Such  diseases  spread  more  or  less  rapidly,  by  contagion 
or  otherwise,  so  as  to  incapacitate  or  destroy  great  numbers  of  the 
people. 

In  illustration  of  the  extent  to  which  an  epidemic  may  incapaci- 
tate a  community  we  need  only  take  the  unhappily  too  familiar 
instance  of  Influenza,  so  expressively  called  by  the  French  "  La 
Grippe."  In  1510,  an  epidemic  of  this  disease  swept  over  Europe, 
"not  missing  a  family  and  scarce  a  person."0  Mercatus  asserts 
that  before  the  beginning  of  autumn,  1557,  influenza  attacked  all 
parts  of  Spain  at  once,  so  that  the  greatest  part  of  the  population 
in  that  kingdom  were  seized  with  it  almost  on  the  same  day.d  In 
1782,  again,  Admiral  Kempenfelt  sailed  from  Spithead  with  a 
squadron  on  May  2.  Influenza  broke  out  on  the  29th,  and  so  many 
men  were  in  consequence  rendered  incapable  of  duty  that  the  whole 
squadron  had  to  return  into  port  about  the  second  week  in  June.e 

But,  unfortunately,  epidemic  visitations  destroy  life  as  well  as 
incapacitate  the  living.  It  is  true  that  modern  Preventive  Medi- 
cine has  lessened  the  evil  to  a  remarkable  extent,  but  nevertheless 

a  Gk.  iv,  in  or  among  ;  Srj/ios,  the  people — ivSyfiew,  to  live  at  or  in  a  place. 

b  Gk.  %m,  upon  ;  Sij/j,os,  the  people — i/juSTifneai,  to  be  among  a  people,  to  be 
prevalent  or  epidemic. — Hippocrates. 

c  Short's  Chronological  History  of  the  Weather.  Vol.  I.,  page  204.  Also 
I?ict.  des  Sciences  med.     Art.  "  Grippe." 

a  See  Report,  by  Dr.  Glass,  in  Lettsom's  Memoir  of  Dr.  Fothergill.  Quarto. 
Page  625. 

e  Lectures  on  the  Principles  and  Practice  of  Physic.  By  Sir  Thomas  Watson, 
Bart.,  M.D.     Third  Edition.     Vol.  II.,  p.  41. 


MICRO-PARASITIC    DISEASES.  21 

the  death-roll  from  epidemic  disease  remains  an  opprobrium  medi- 
cinae.  In  1871-72  small-pox  caused  1,647  deaths  in  Dublin  alone. 
The  outbreaks  of  influenza  in  1890  and  1891  raised  the  death-rate 
in  many  American  and  British  towns  to  an  appalling  figure.  It  is 
estimated  that  the  plague  of  London  in  1666  slew  70,000  persons  ; 
but  even  this  fades  into  insignificance  when  contrasted  with  the 
plague  of  1348 — a  pestilence  which  carried  off  100,000  souls  in 
London  alone  and  40,000,000  from  all  Europe. 

3.  Sporadic  a  is  a  term  applied  to  solitary,  isolated,  or  scattered 
cases  of  specific  fevers  or  micro-parasitic  diseases,  which  occur 
independently  of  any  known  epidemic  or  contagious  influences 
from  accidental  or  undiscovered  causes.  Such  outbreaks  often 
take  place  in  the  wake  of  a  past  epidemic. 

4.  The  term  Pandemicb  is  used  when  a  disease  prevails  in  suc- 
cession in  a  very  large  number  of  countries ;  when  it  sweeps,  like 
a  great  wave,  across  large  areas  of  the  earth's  surface:  thus,  in 
1847-48  and  again  in  1889-91,  there  was  a  pandemic  prevalence 
of  influenza;  and  in  1869-73,  a  similar  pandemic  prevalence  of 
smallpox  was  observed. 

Theories  of  Immunity. — One  of  the  most  interesting  facts  con- 
nected with  the  micro-parasitic  diseases  is  the  immunity  against  a 
subsequent  attack  which  their  victims  in  most  eases  acquire.  This 
freedom  from  a  second  attack  by  reason  of  the  influence  exerted  by 
a  first  attack  is  not  easily  explained  ;  nor  is  it  observed  to  the  same 
degree  after  the  different  diseases.  Thus,  an  attack  of  smallpox 
confers  almost  absolute  immunity  from  a  second  visitation.  The 
protective  efficacy  of  an  attack  of  measles  is  less  complete,  a  second 
attack  of  scarlatina  is  not  uncommon,  while  an  attack  of  erysipelas 
actually  seems  to  predispose  to  a  second.  Among  the  Continued 
Fevers,  the  same  rule  of  immunity  in  general  holds  good,  and  yet 
Dr.  Charles  Murchison  in  his  own  person  suffered  from  two 
unequivocal  attacks  of  maculated  typhus.0 

a  Gk.  tnr6pas,  scattered  (from  crireipo),  I  sow). 

b  Gk.  irSs,  all ;  Srj/ios,  the  people. 

c  A  Treatise  on  the  Continued  Fevers  of  Great  Britain.  By  Charles  Murchison, 
M.D.,  LL.D.,  F.R.S.  Third  Edition,  edited  by  W.  Cayley,  M.D.,  F.E.C.P. 
London  :  Longmans,  Green,  &  Co.     1884.     Page  84. 


22  MICRO-PARASITIC   DISEASES. 

The  importance  of  investigating  this  question  of  acquired 
immunity  will  be  apparent  when  we  reflect  that  to  secure  this 
immunity  has  been  the  object  of  the  preventive  treatment  of 
zymotic  disease  by  inoctdation  of  an  attenuated  virus — that  is,  a 
virus  of  diminished  or  weakened  poisonous  properties — from  the 
days  of  Lady  Mary  Wortley  Montague  a  to  those  of  Pasteur,  Tous- 
saint,  and  Koch. 

The  question  is  still  a  vexed  one.  It  is  well  discussed  by  Dr. 
Edgar  Oookshank  in  his  "  Manual  of  Bacteriology." b  One  theory 
is  that  during  an  attack  of  an  infective  disease  some  chemical 
substance — a  toxin  or  a  ptomain — is  secreted,  which  remaining  in  the 
system  defeats  a  future  onset  of  the  specific  microbe  of  the  disease. 

Again,  it  is  suggested  that  at  their  first  invasion  of  the  animal 
system  the  micro-organisms  exhaust  the  pabulum  in  the  blood  and 
tissues  which  they  require  for  their  nutrition,  and  so  leave  the  soil 
impoverished  and  unsuitable  for  the  development  hereafter  of  their 
successors  of  the  same  species. 

Another  theory  is  that  the  tissues  are  endowed  with  some  power 
of  vital  resistance  to  the  development  of  micro-organisms,  and  that 
this  power  exists  in  some  species  and  individuals  to  a  high  degree, 
thus  constituting  what  is  called  "  natural  immunity."  This  theory, 
however,  does  not  explain  the  acquired  immunity  of  which  we  are 
now  speaking,  just  as  the  second  theory  does  not  explain  natural 
immunity.  As  Dr.  Crookshank  well  remarks  :  "  One  would  expect 
that  the  vital  resistance  would  invariably  be  lowered  by  a  previous 
attack,  and  increased  liability  be  the  conslant  result." 

One  more  theory  remains,  and  it  constitutes  a  very  romance  in 
Pathology.  It  is  the  theory  of  Phagocytosis0  and  its  results.  In 
1884,  Elias  Metschnikoff,  of  Odessa,  communicated  to  Virchow's 
Archiv.  fur  pathologist e  Anatomie  vnd  Physiologic  unci  fur  klinische 
Medicin  a  paper   on   a  "  Blastomycetic   Disease   in   Daphniad — a 

a  See  Chapter  X.,  page  103. 

b  Second  Edition.     London  :  H.  K  Lewis.     1887.     Pages  169,  et  seq. 

c  Gk.  <pay4w,  I  devour;  kvtos,  a  hollow,  hence,  a  cell.  "Phagocytes"  are 
"devouring  cells." 

d  Ueber  eine  Sprosspilzkrankheit  der  Daphnien.  Beitrag  zur  Lehre  liber 
den  Kanipf  der  Phagocyten  gegen  Krankheitserreger. 


MICUO-PARASITIC    DISEASES.  23 

contribution  to  our  knowledge  of  the  War  of  the  Phagocytes 
against  Pathogenic  Microbes."  Daphnia,  or  "  water-fleas,"  are  a 
genus  of  small  fresh- water  entomostracans,  one  of  the  sub-classes  of 
the  Crustacea.  Metschnikoff  followed  up  this  paper  by  a  further 
communication  on  "The  Relation  of  Phagocytes  to  the  Bacillus 
anthracisJ"3,  According  to  the  author,  the  leucocytes  or  white-blood 
corpuscles  appear  to  have  the  power  of  destroying  bacteria  in  some 
cases.  If  the  bacilli  of  anthrax  are  inoculated  in  the  frog,  the 
white  blood  cells  are  seen  to  incorporate  and  destroy  them  until 
they  entirely  disappear,  and  the  animal  is  not  affected.  If,  how- 
ever, the  animal  is  kept  at  a  high  temperature  after  inoculation, 
the  bacilli  increase  so  rapidly  that  they  gain  the  upper  hand  over 
the  leucocytes,  and  the  animal  sickens  and  succumbs.  In  the 
septicaemia  of  mice  the  white  blood  cells  are  attacked  and  disin- 
tegrated by  the  bacilli  in  a  like  manner. 

The  leucocytes,  then,  may  be  regarded  as  a  soldier-like  commu- 
nity, one  of  whose  special  offices  is  to  fight  to  the  death  the  invading 
hordes  of  pathogenic  microbes.  Hence  Metschnikoff's  expressive 
term — "Der  Kampf  der  Fresszellen  (Phagocyten)  gegen  Krank- 
heitserreger" — "  The  battle  of  the  devouring  cells  against  the  causes 
of  disease."  These  fighting  leucocytes  have  been  called  phago- 
cytes. They  are  endowed  with  powers  of  movement,  and,  amoeba- 
like, are  capable  of  pushing  out  and  withdrawing  portions  of  their 
protean  bodies.  Into  the  retracted  portion  of  one  of  these  phago- 
cytes a  microbe  is  received.  By  it  it  is  finally  enveloped,  becomes 
cloudy,  and  finally  disappears  by  complete  absorption  or  digestion. 
When,  on  the  other  hand,  victory  inclines  to  the  invader,  then  there 
is  sufficient  disturbance  of  function  to  produce  pyrexia  and  other 
febrile  symptoms. 

Mr.  A.  Winter  Blyth,  whose  graphic  description  of  "  Micro- 
Strife"13  we  have  closely  followed,  says  that  "  by  the  same  theory 

a  Ueber  die  Beziehung  der  Phagocyten  zu  Milzbrandbacillen.  Virchow's 
Arckiv.  Vol.  XCVII.,  page  502.  1884.  "Anthrax"  is  also  called  "Splenic 
Fever,"  "Malignant  Pustule,"  or  "Wool-sorter's  Disease." 

b  A  Manual  of  Tublic  Health.  London  :  Macruillan  &  Co.  1890.  Pp.  363, 
et  seq. 


24  MICRO-PARASITIC    DISEASES. 

the  curious  fact  that  an  animal  body  having  once  recovered  from  one 
of  these  micro-parasitic  diseases  obtains  a  shorter  or  longer  immunity 
is  capable  of  a  plausible  explanation.    The  macrophages  [phagocytes] 
have  a  rapid  cycle  of  existence,  a  few  hours  may  represent  several 
generations,  so  that  acquired  properties  are  rapidly  transmitted ; 
those  poisoned  by  the   excretion   of   pathogenic  microbes  perish, 
those  that  more  or  less  effectually  resist,  continue  to  live  and  pro- 
pagate, until  by  a  repetition  again  and  again  of  this  process,  the 
body  may  be  full  of  resistant  living  particles,  and  the  foreign  tribe 
is  annihilated  or  expelled.     If  now  a  second  inimical  colony  of  the 
same  kind  obtains  access  to  the  body,  it  meets  with  the  fighting 
descendants  of  the  old  heroes,  and  the  attack  is  immediately  re- 
pulsed, and  this  is  the  nature  of  protection  conferred  from  a  recovery 
from  a  first  attack.     Since  it  would  seem  that  the  weapon  of  the 
microbe  is  its  venom,  it  is  not  surprising  that  the  macrophages  may 
be  educated  in  their  resistance  by  being  dosed  with  the  excretory 
products  of  pathogenic  organisms  ;  the  method  of  education  being- 
first,  doses  feeble  in  either  quantity  or  strength,  to  be  followed  by 
successive  doses  of  gradually  increasing  virulence,  until  no  health 
disturbance  is  produced  by  an  otherwise  mortal  dose." 

Mr.  Blyth  goes  on  to  give  a  practical  example  in  illustration  of 
this  theory  of  acquired  immunity.  "The  efficacy,"  he  says,  "of 
ordinary  vaccination  against  smallpox  may  be  explained  on  the 
theory  that  vaccine  contains  a  number  of  degenerate  colonies  of  the 
same  genus  as  the  smallpox  microbe — these  are  conquered  with 
comparative  ease ;  nevertheless,  the  result  is  that  a  race  of  macro- 
phages is  left,  which  from  their  education  successfully  cope  with 
the  virulence  of  true  variola."  a 

Such  is  the  ingenious  and  suggestive  theory  of  phagocytosis  and 
its  relation  to  acquired  immunity. 

Certain  of  the  infective,  or  micro-parasitic,  diseases  are  charac- 
terised by  the  appearance  at  a  definite  period  in  their  course  of  a 
rash  on  the  skin,  or  "  an  eruption."  Others  run  a  continued  febrile 
course  from  the  beginning,  while  in  a  third  group  periods  of  complete 
or  partial  freedom  from  fever — apyrexia— occur  from  time  to  time. 
8  Loc.  eit.     Page  365. 


MICRO-PARASITIC    DISEASES.  25 

Bearing  these  clinical  facts  in  mind  we  may  adopt  the  following 
classification  of  micro-parasitic  febrile  diseases,  exclusive  of  sep- 
ticaemia : — 

I.  The  Eruptive  Fevers,  or  Exanthemata — 

1 .  Variola,  or  Smallpox. 

2.  Varicella,  or  Chickenpox. 

3.  Morbilli,  or  Measles. 

4.  Scarlatina,  or  .Scarlet  Fever. 

5.  Epidemic  Roseola,  or  Epidemic  Rose  Rash  (Germ.  Rotheln). 

6.  Erysipelas,  or  St.  Anthony's  Fire,  or  Rose. 

II.  The  Continued  Fevers — 

1.  Febricula,  Simple  Fever,  or  Ephemeral  Fever. 

(This  is  sporadic  in  its  mode  of  prevalence,  and  is  by 
some  authors  supposed  to  be  of  non-specific  origin). 

2.  Enteric,  Typhoid,  or  Pythogenic  Fever — 

(Specific,  endemic,  and  locally  epidemic). 

3.  Typhus  Fever — 

(Specific,  epidemic,  and  infectious). 

4.  Spirillum  Fever,  Famine  Fever,  or  Relapsing  Fever — 

(Specific,  epidemic,  and  infectious). 

III.  The  Intermittent  Fevers — 

1.  Malarial  Fever,  or  Ague — 

(Quotidian,  Tertian,  Quartan). 

2.  Remittent  Fever,  or  Jungle  Fever. 

As  regards  the  behaviour  of  the  temperature  in  the  foregoing 
diseases,  the  following  terms  are  used : — 

1.  The  onset  or  invasion,  during  which  the  temperature  rises 

more  or  less  rapidly  and  evenly.     This  is   called  by 
Wunderlich  the  initial  period  or  pyrogenetic  stage* 

2.  The  acme,   or  fastidium,  during  which  the  thermometer 

reads  highest.     The  period  of  full  development  of  the 
fever  accompanying  the  disease. 

3.  The  cooling,  or  defervescence,  during  which  the  tempera- 

*  On  the  Temperature  in  Diseases :  a  Manual  of  Medical  Thermometry. 
By  Dr.  C.  A.  Wunderlich.  Translated  by  W,  Bathurst  Woodman,  M.D. 
London  :  The  New  Sydenham  Society.     1871.     Page  9. 


26  MICRO-PARASITIC   DISEASES. 

ture  falls  more  or  less  rapidly  and  evenly.  The  period 
of  return  to  normal  temperature. 

4.  The  crisis,  characterised  by  a  sudden  and  abrupt  fall  of 

temperature  and  an  amelioration  in  the  other  symptoms. 
This  is  rapid  defervescence. 

5.  The  lysis,  during  which  the  temperature  gives  way  slowly 

and  gradually,  with  morning  remissions  and  evening 
exacerbations.     This  is  protracted  defervescence. 

6.  The  collapse  stage,   characterised  by  marked  subnormal 

temperature.  This  stage,  although  seemingly  dan- 
gerous, is  deceptive,  and  commonly  ends  in  recovery. 

7.  The  hectic  state,  denoted  by  habitual  fever  with  large  daily 

range   of   temperature.     The    febrile   type   is   usually 

remittent,  with  one  or  two  exacerbations  in  the  course 

of  every  day,  and  is  chronic  or  of  long  duration. 

For  convenience  of  description  the  cyclical  course  run  by  these 

specific  fevers  is  portioned  off,  or  mapped  out,  into  the  stages  which 

follow — 

1.  Incubation — the  "hatching"  stage  is  sometimes  spoken  of 

as  the  latent  period,  because  as  a  rule  it  is  characterised 
by  no  special  symptoms.  The  period  of  incubation  is 
the  time  which  elapses  between  the  exposure  to  the 
poison  of  the  disease  and  its  reception  into  the  system 
and  the  appearance  of  the  earliest  symptoms.  This 
stage  varies  greatly  in  the  different  infectious  fevers : 
its  probable  duration  in  each  case  will  be  found  under 
the  heading  of  each  disorder,  as  well  as  in  the  Table  at 
the  close  of  this  chapter. 

2.  Invasion — the  stage  during  which  the  special  symptoms; 

and  in  particular  the  fever,  are  developing.  For  this 
reason  it  is  called  by  Wunderlicha  the  pyrogenetic 
stage,  and  in  the  case  of  the  eruptive  fevers,  as  it 
precedes,  or  runs  before,  the  appearance  of  the  rash,  it 
is  spoken  of  as  the  prodromal b  stage.     Like  the  period 

a  Medical  Thermometry.     New  Syd.  Soc.     Pages  9,243. 
b  Gk.   wp6Sfofj.os,  a  running  before,  a  going  in  advance. 


MICRO-PARASITIC    DISEASES.  27 

of  incubation,  it  also  varies  considerably  in  duration  in 
the  several  diseases,  begins  with  the  earliest  symptoms 
and  terminates  with  the  fast  igi urn  of  the  disorder,  or 
(in  the  case  of  the  eruptive  fevers)  with  the  appearance 
of  the  rash. 

3.  Eruption — the  stage  of  the  rash. 

4.  Defervescence11 — the    cooling    stage,    already    described. 

The  German  equivalent,  Fieberabnahme,  is  very  expres- 
sive. 

5.  Desquamation b — the    peeling  stage    (Germ.    Abschuppimg 

or  Absplitteriing),  during  which  the  skin  is  shed  either 
in  small  particles,  like  fine  bran,  as  in  measles — 
when  it  is  spoken  of  as  "  branny  "  or  "  furf uraceous  " 
(Lat.  furfur,  bran)  desquamation ;  or  in  flakes,  as  in 
scarlatina,  when  it  is  called  "flaky,"  "membranous," 
or  "  lamellar "  (Lat.  lamella,  a  small  plate)  desquam- 
ation. 

6.  Convalescence  c — restoration   to   health   and   strength — a 

stage  which  lasts  from  the  termination  of  the  disease 

and  the   final   disappearance  of  its  symptoms   to  the 

recovery   of    the    strength    lost    through    it    by   the 

patient. 

The  following  Table  will  prove  of  use  in  connection  with  the 

foregoing  definitions.     The  terms  "  Quarantine"  and  "Isolation," 

which  head  the  last  two  columns  in  the  Table,  require  explanation. 

"  Quarantine  (no  longer  used  with  its  original  signification  of  a 

forty  days'  [Fr.  Quarante,  forty]  detention)  means  the  segregation 

of  possibly  infected  persons  until  after  the  period  has  elapsed  at 

which  they  would  (if  infected)  develop  characteristic  signs  of  the 

disease.     Isolation,  on  the  contrary,  implies  the  continued  separa- 

a  Lat.  defervesco,  to  cease  boiling,  leave  off  raging,  cool  down — a  Ciceronian 
word. 

b  Lat.  desquamo,  to  scale  off,  to  peel  off  {Squama,  a  scale,  or  flake). 

c  Lat.  convalesco,  to  recover  from  a  disease,  to  regain  health,  to  grow  strong, 
gain  strength.  These  are  all  classical  meanings  of  the  word,  frequently  met 
with. 


28  MICRO-PARASITIC    DISEASES. 

tion  of  the  infectious  patient  from  the  healthy  until  after  he  has 
ceased  to  be  infectious."  a 

It  is  right  to  mention  that  some  authors  include  in  the  period  of 
incubation  the  invasion-stage.  According  to  them,  therefore, 
incubation  is  divided  into  two  stages,  those  of  latency  and  of 
invasion.  In  this  book  incubation  and  latency  are  treated  as 
synonymous  terms,  and  invasion  is  treated  as  a  separate  and 
distinct  period. 

The  doctrine  promulgated  by  John  Hunter b  in  the  eighteenth 
century,  that  the  presence  of  one  of  the  micro-parasitic  diseases 
protects  the  infected  individual  from  an  attack  of  another  disease 
belonging  to  the  same  group  cannot  be  entertained  or  accepted 
for  a  moment.  All  clinical  experience  is  opposed  to  such  a  view, 
and  in  the  following  pages  allusion  will  be  made  from  time 
to  time  to  instances  of  individuals  contracting  an  eruptive  or  a 
continued  fever  while  actually  under  treatment  for  another  febrile 
disease. 

In  fact,  it  may  be  laid  down  as  a  general  rule  that  the  presence 
of  one  infective  disease  increases  rather  than  diminishes  the 
susceptibility  of  the  sufferer  to  another  by  impairing  his  health 
and  so  lessening  his  powers  of  resistance.  The  curious  fact  that 
vaccination  seems  often  to  influence  the  progress  of  whooping- 
cough  for  the  better  does  not  militate  against  the  view  here  put 
forward,  for  if  it  did  the  operation  of  vaccination  would  not  have 
proved  successful  in  such  cases.0 

aSee  Art.  "Disinfection,"  by  C.  E.  Shelly,  M.A.,  M.D.,  in  Fowler's 
Dictionary  of  Practical  Medicine.     London  :  J.  &  A.  Churchill.     1890. 

b  Hunter's  Works,  Palmer's  Edition.     Vol.  I.,  page  313.     Vol.  III.,  page.  4. 

c  Cf.  Dr.  Cachazo  (Wien.  med.  Blatter,  October  16,  1890),  Dr.  Emile  Mtiller 
(Gazette  Medical  de  Strasbourg,  July  1,  1891),  and  Dr.  Thomas  Purcell  (Brit. 
Med.  Journ.,  August  29,  1891,  page  498). 


MICRO-PARASITIC    DISEASES. 


29 


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30 


CHAPTER  IV. 

The  General  Principles  of  Treatment  of  the 
Eruptive  and  Continued  Fevers. 

Preventable  Diseases. — Preventive  Treatment,  or  Prophylaxis. — Disinfec- 
tion:— Antiseptics,  Disinfectants,  Germicides,  and  Deodorants. — Dr.  Shelly 's 
Classification  of  Disinfectants. — Dr.  Emerson  Reynolds'  General  Plan  of 
Disinfection. — Official  Regulations  for  Disinfection  adopted  in  Berlin. — 
Disinfection  within  the  Living  Body. — Receptivity. — Exciting  and  Predis- 
posing Causes  of  Disease. — Acquired  and  Natural,  or  Hereditary,  Predisposition 
to  Disease. — The  chief  Predisposing  Causes  of  Febrile  Disorders. 

Part  I. — Preventive  Treatment,  or  Prophylaxis. 

Having  regard  to  tlie  view  that — (1)  the  diseases  we  are  con- 
sidering result  from  the  introduction  into  the  system  of  a  specific 
micro-organism,  which  either  acts  as  a  poison  itself  or  produces  in 
the  body  a  toxic  agent  of  a  chemical  nature,  while  (2)  the  "  suscep- 
tibility" or  "  receptivity  "  of  the  infected  individual  varies  without 
limit,  according  to  his  healthy  or  unhealthy  surroundings,  his  state 
of  health  at  the  time,  and  a  natural  or  acquired  immunity — we 
are  justified  in  speaking  of  specific  infectious  (infective)  diseases  as 
preventable. 

As  this  is  so,  it  follows  that  the  subject  of  treatment  arranges 
itself  under  two  headings — preventive  and  curative.  Both  these 
terms  must  be  used  with  a  certain  amount  of  reservation — in  a 
general  rather  than  in  a  precise,  an  abstract,  or  an  absolute  sense. 

From  this  point  of  view  we  may  adopt  the  terms  "  Preventive 
Medicine"  and  " Prophylaxis " a  with  all  reverence  and  with  the 
utmost  propriety. 

The  prophylaxis  of  the  acute  specific  fevers  consists  in — (1) 
the  destruction  of  the  virus  or  contagium  before  it  can  enter  the 
system ;  (2)  the  adoption  of  measures  which  will  have  the  effect 
of  lessening  the  receptivity  of  the  individual,  or — in  other  words — 

a  Gk.  TTpo<pvAd(rcra>,  fut.  Trpo<pv\d£u),  to  keep  guard  before,  to  guard  against,  to 
be  on  one's  guard  against ;  and,  in  medical  sense,  to  take  precautions  against. — 
(Plutarch). 


PREVENTIVE  TREATMENT,  OR  PROPHYLAXIS.     31 

of  increasing  his  powers  of  resistance  ;  and  (3)  the  strict  enforce- 
ment of  rules  relating  to  quarantine  and  isolation. 

I.  The  destruction  of  the  virus  or  contagium  of  infectious  dis- 
orders is  achieved  by  disinfection,  using  the  term  in  its  strict 
etymological  sense  to  denote  any  process  by  which  the  contagium 
of  a  given  disease  may  be  destroyed  or  rendered  inert,  so  as  to 
render  impossible  the  spreading  of  that  disease. 

Antiseptics  must  be  distinguished  from  disinfectants.  An 
antiseptic  is  a  substance  which  prevents  or  retards  putrefaction — 
that  is,  the  decomposition  of  animal  or  vegetable  bodies  accom- 
panied by  the  evolution  of  offensive  gases. 

A  true  disinfectant,  on  the  contrary,  is  a  substance  which  exerts 
a  destructive  action  upon  minute  living  organisms — the  microbes 
of  which  we  have  been  speaking  so  often,  and  upon  dead  organic 
matter. 

A  germicide,  again,  is  a  disinfectant  which,  when  added,  in  not 
less  than  a  certain  proportion,  to  a  culture  of  the  particular  microbe 
under  observation,  kills  both  it  and  its  spores  outright. 

Apart  from  either  antiseptics  or  disinfectants,  we  have  a  third 
class  of  chemical  agents  which  remove  bad  smells,  and  hence  are 
called  deodorants.  Although  many  substances  are  at  the  same 
time  antiseptics,  deodorants,  and  disinfectants — for  example,  chlo- 
rine, ozone,  and  some  of  the  metallic  salts — yet  it  would  be  a  fatal 
error  to  suppose  that  the  removal  of  a  bad  smell,  probably  the 
result  of  sepsis,  or  putrefaction,  can  in  any  sense  be  regarded  as 
evidence  of  true  disinfection.  As  a  matter  of  fact,  the  volatile 
poisons  of  the  infectious  fevers  are  often  odourless,  and  mere 
deodorants  are  not  called  for  in  dealing  with  them. 

Dr.  C.  E.  Shelly  classifies  disinfectants  according  to  their  mode  of 
action  as  — 

A.  Oxidising  agents,  including  (1)  those  which  oxidise  directly — 
e.g.,  ozone,  potassium  permanganate,  &c,  and  (2)  those  which 
oxidise  indirectly  by  the  abstraction  of  hydrogen — e.g.,  chlorine, 
chloride  of  lime,  &c. 

B.  De-oxidising  agents — e.g.,  carbolic  acid,  sulphurous  acid  gas, 
&c. 


32  GENERAL   PRINCIPLES   OF   TREATMENT. 

C.  Substances  which  destroy  the  pathogenic  virus  by  some  other 
form  of  physical  action — e.g.,  corrosive  sublimate,  heat,  &c. 

"It  is  obvious,"  writes  Dr.  Shelly,  "  that  the  members  of  groups 
A  and  B  must  not  be  used  together,  since  their  modes  of  action  are 
chemically  antagonistic ;  thus,  carbolic  acid  may  be  employed  in 
conjunction  with  the  fumes  of  burning  sulphur,  but  neither  should 
be  used  with  Condy's  fluid,  chlorine  gas,  or  sanitas. 

"  The  contagia  of  the  various  forms  of  infection  vary  greatly  as 
regards  their  virulence  and  their  power  of  resistance  to  destructive 
agencies ;  the  spores  of  Bacillus  anthracis  and  the  virus  of  scarla- 
tina are  tenacious  of  vitality,  whilst  the  infection  of  measles  is 
short-lived  and  can  be  destroyed  by  free  exposure  to  fresh  air  and 
bright  sunshine."a  This  last  remark  applies  to  the  contagium  of 
typhus  fever  also. 

Dr.  Emerson  Reynolds,  F.R.S.,  Professor  of  Chemistry  in  the 
University  of  Dublin,  some  years  ago  laid  down  the  following 
general  plan  of  disinfection  in  dealing  with  a  case  of  infectious 
disease b : — 

"The  patient's  stools  and  vomited  matter  should  be  immediately 
treated  by  free  sprinkling  with  a  roughly-powdered  mixture  of  four 
parts  of  common  sulphate  of  iron  (copperas)  and  one  part  of  sulphate 
of  copper  (blue  stone).  If  necessary  a  little  water  may  be  thrown 
into  the  vessels,  in  order  to  facilitate  solution  of  the  salts.  All 
articles  of  clothing,  however  trifling,  pieces  of  cloth,  books,  toys, 
&c,  used  by  the  patient,  should  be  set  aside,  the  worthless  articles 
and  those  of  little  value  to  be  burned  as  soon  as  possible,  and  the 
clothing,  &c,  to  be  treated  as  we  shall  describe  further  on.  Of  all 
the  bodies  used  to  'purify'  the  atmosphere  of  a  sick  chamber, 
chloride  of  lime,  made  into  a  paste  with  water  and  spread  on  plates, 
is,  perhaps,  least  open  to  objection.  If  the  smell  proves  disagree- 
able to  a  patient,  '  Condy's  fluid '  may  be  substituted,  though  the 
non-volatility  of  the  active  ingredient  (permanganate  of  potassium) 
renders  it  less  effective.     It  is  well  to  remember  that,  when  used 

a  Art.  "  Disinfection,"  in  Fowler's  Dictionary  of  Practical  Medicine. 
»  Cf.  Manual  of  Public  Health  for  Ireland.      Dublin :  Fannin  &  Co.     1875. 
Pages  263,  et  seq. 


PREVENTIVE    TREATMENT,    OR    PROPHYLAXIS.  33 

in  this  manner,  both  the  above-named  bodies  probably  act  only  as 
deodorants.  Perfect  cleanliness  in  the  sick  chamber  and  good 
ventilation  are  of  vastly  greater  importance  than  the  use  of  any 
known  disinfectant  that  could  be  safely  employed  under  the  circum- 
stances. But,  if  it  be  desired  to  try  general  disinfection,  we 
decidedly  give  the  preference  to  the  occasional  burning  of  ordinary 
incense,  mixed  with  about  one-sixth  of  its  weight  of  benzoic  acid, 
in  different  parts  of  the  house,  while  carbolic  or,  better  still, 
cresylic  acid  may  be  used  in  water-closets,  &c.  At  the  termination 
of  an  illness,  the  room  or  rooms  occupied  by  the  patient  should  be 
cleared  of  furniture,  carpeting,  curtains,  &c,  the  paper  removed 
from  the  walls,  the  chimney  stopped,  and  windows  well  closed.  A 
large  earthenware  basin  is  then  placed  in  the  centre  of  the  room. 
If  the  apartment  be  of  moderate  size,  put  half  a  pound  of  copper 
wire,  cut  in  short  pieces,  into  the  basin,  and  pour  upon  it  three 
times  its  weight  of  aquafortis  (strong  commercial  nitric  acid), 
diluted  with  its  own  bulk  of  water.  Action  speedily  commences, 
and  ruddy  fumes  are  evolved,  consisting  of  oxides  of  nitrogen. 
The  door  of  the  room  is  now  carefully  closed,  and  not  opened  for  a 
few  days ;  then  a  shovel,  containing  a  few  pieces  of  red-hot  coal, 
is  brought  into  the  room,  and  two  or  three  ounces  of  sulphur  are 
thrown  on  the  coals.  The  sulphur  burns,  and  produces  abundance 
of  sulphur  dioxide,  commonly  called  sulphurous  acid ;  the  door  is 
again  secured.  After  a  day  or  two  the  room  may  be  entered,  the 
windows  thrown  open,  the  ceilings  whitened,  the  walls  papered, 
and  the  woodwork  and  flooi-s  washed  with  water  containing  a  tea- 
spoonful  of  benzoic  acid  per  gallon. 

"  Articles  of  clothing  which  will  admit  of  the  treatment  should 
be  boiled  with  water  first,  and  then  be  steeped  for  some  days  in  fresh 
water,  containing  benzoic  acid  in  the  proportion  of  a  large  teaspoon- 
ful  of  the  common  acid  for  every  five  gallons  of  water.  Let  the 
articles  then  be  boiled  in  the  steep-water,  and  next  washed  as  usual. 
"Although  the  best  and  safest  course  unquestionably  is  to  burn 
all  clothes,  bedding,  hangings,  &c,  we  may  attempt  the  destruction 
of  the  contagion  particles  by  heating  to  a  much  higher  temperature 
than  that  of  boiling  water,  though  not  to  such  a  temperature  as  to 

D 


34  GENERAL   PRINCIPLES   OF   TREATMENT. 

destroy  the  material  operated  upon.     The  temperature  of  260°  F. 
is  about  the  highest  that  ordinary  fabrics  can  bear  for  any  length 
of  time,  and  this  heat  may  be  applied  by  enclosing  the  articles  in  a 
large  oven  of  brick  or  iron,  raised  to  the  required  temperature  by  a 
coil  of  metal  pipe,  through  which  more  or  less  of  the  hot  gases  from 
a  small  furnace   can  be   directed,   according   to  the  temperature 
desired.     The  precise  degree  can  be  determined  by  a  thermometer, 
whose  stem  passes  through  the  door  of  the  chamber.     A  tube  should 
convey  the  effluvia  of  the  clothes  from  the  upper  part  of  the  oven  to 
the  ashpit  of  a  furnace,  in  order  that  the  gaseous  or  other  exhala- 
tions may  be  burnt,  and  so  prevented  from  polluting  the  atmosphere. 
"  It  is  comparatively  difficult  to  regulate  the  temperature  of  a  large 
chamber  heated  in  this  way,  or  to  ensure  the  thorough  treatment 
of  the  articles   enclosed    in   it.     We  would   much   prefer   to   use 
several  small  steam-tight  chambers,  and  to  connect  them  directly 
with  a  boiler.     The  steam  should  be  allowed  to  pass  freely  into 
each  disinfecting  chamber,  from  which  it  might  issue  at  a  pressure 
of  about  20  lbs.     A  temperature  of  230°  F.  is  supposed  to  destroy 
all  living  organisms ;  but  a  temperature  of  250°  F.  can  be  easily 
reached  and  maintained  economically  by  the  steam  under  pressure, 
and  since  the  heat  is  also  more  evenly  distributed  in  the  steam  than 
in  the  air  chamber,  we  give  the  preference  to  the  former.     The 
time  during  which  articles  must  be  subjected  to  a  high  temperature 
varies  with  the  thickness  of  material,  and  the  facility  with  which 
it  conducts  heat.     It  is  usual  to  leave  such  articles  as  pillows  in 
the  hot-air  chambers  for  as  much  as  five  or  six  hours.     We  need 
scarcely  add  that  every  town  should  be  provided  with  at  least  one 
chamber  for  disinfection  with  the  aid  of  heat." 

The  writer  of  the  foregoing  remarks  has  recently  (1890)  described 
a  new  and  powerful  disinfectant,  which  is  a  liquid  combination  of 
sulphur  dioxide,  camphor,  and  various  volatile  aromatic  bodies. 
This  material — named  Thiocamf — possesses  the  remarkable  pro- 
perty of  giving  off  a  very  large  volume  of  effective  germicides  on 
mere  exposure  to  the  atmosphere,  and  can  be  advantageously  used 
for  disinfecting  a  room  instead  of  the  treatment  with  nitrous  fumes 
described  above.     The  air  of  the  closed  room  is  first  moistened  by 


PREVENTIVE  TREATMENT,  OR  PROPHYLAXIS.     35 

sprinkling  hot  water  freely  about ;  a  sufficient  quantity  of  Thiocamf 
is  poured  on  a  large  flat  dish  or  old  tray,  and  the  place  is  shut  up  for 
two  days.  The  usual  thorough  cleansing  of  the  apartment  should 
then  take  place.  About  six  fluid  ounces  of  Thiocamf  are  required 
for  a  small  bedroom,  and  double  that  amount  if  the  room  be  large. 
Although  it  would  be  difficult  to  improve  upon  Professor  Emer- 
son Reynolds'  plan  of  disinfection  just  described,  the  importance  of 
the  subject  justifies  some  account,  of  the  official  regulations  for  dis- 
infection adopted  in  Berlin.  Under  date  of  August  15,  1883,  the 
municipal  authorities  of  that  great  city  published  regulations,  of 
which  the  following  is  a  synopsis,  for  disinfection  in  cases  of 
catching  or  contagious  diseases  : — 

"Especially  powerful  disinfection  methods  are  necessary  in  small- 
pox, diphtheria,  cholera,  typhoid  and  typhus  fevers.  Disinfection 
is  also  obligatory,  although  less  powerful  methods  may  be  used  in 
scaidet  fever,  dysentery,  and  measles.  It  may  also  be  required  in 
some  cases  of  whooping-cough,  consumption,  contagious  inflamma- 
tion of  the  lungs  and  eyes,  splenic  fever,  glanders,  puerperal  fever, 
hydrophobia,  and  septicaemia.  The  means  of  disinfection  specified 
are  strong  potash  soap,  carbolic  acid,  corrosive  sublimate,  carbolic 
acid  spray,  chlorine,  ventilation,  dry  heat,  steam  and  burning. 
Corrosive  sublimate  is  employed  only  in  the  most  contagious  forms 
of  disease,  and  its  application  should  be  directed  by  a  physician. 
For  the  disinfection  of  furnished  apartments  everything  used  by  the 
sick  person  which  can  be  washed  should  be  placed  with  as  little 
shaking  or  agitation  as  possible  into  a  vessel  placed  in  the  sick 
chamber,  containing  a  solution  of  the  potash  soap.  They  are  to  be 
removed  in  this  vessel  for  cleansing. 

"  Bandages,  &c,  used  in  dressing  wounds  are  to  be  burned,  and 
the  instruments  are  to  be  disinfected  with  carbolic  acid.  Except 
in  special  cases  all  the  secretions  should  be  placed  in  vessels  con- 
taining soap  solution.  Offensive  odours  should  not  be  combated  by 
fumigations  or  perfumes,  but  by  an  abundant  ventilation,  and  as 
far  as  possible  by  the  removal  of  the  causes  which  produce  them. 
It  is  forbidden  to  keep  food  in  the  sick  chamber.  Persons  who 
enter  it  should  abstain  from  eating  or  drinking  while  there.     At 


36  GENERAL    PRINCIPLES   OF   TREATMENT. 

their  exit  they  should  wash  and  cleanse  the  beard,  the  hair,  and  the 
clothing  by  means  of  a  brush  moistened  with  carbolic  acid.  When  it 
is  necessary  to  carry  to  the  hospital  a  person  affected  with  smallpox, 
cholera,  or  typhus,  it  must  be  done  by  vehicles  furnished  by  the 
police.  It  is  forbidden  to  make  use  of  public  vehicles.  When  the 
patient  is  convalescent  he  should  be  bathed  with  the  potash  soap. 

"  Clothing  which  has  been  in  the  chamber  during  the  diseaes 
sliould  be  exposed  to  the  vapours  of  chlorine  before  use.  Corpses 
of  persons  dying  of  a  contagious  disease  should  be  buried  as  soon 
as  possible.  Those  dying  from  small-pox,  diphtheria,  typhus, 
typhoid,  or  cholera,  should  be  wrapped  in  sheets  thoroughly 
moistened  by  a  solution  of  corrosive  sublimate.  For  other  diseases 
clothes  moistened  with  a  solution  of  the  potash  soap  may  be  used. 
Before  sending  the  linen,  clothing,  &c,  of  the  patient,  to  be  washed, 
the  articles  should  be  folded  without  shaking  or  making  a  dust, 
and  placed  in  sheets  dipped  in  the  solution  of  corrosive  sublimate, 
and,  without  unwrapping,  should  be  boiled  for  half  an  hour  in  this 
solution  of  potash  soap,  in  cases  of  smallpox,  diphtheria,  cholera, 
typhoid,  typhus,  splenic  fever,  glanders,  or  hydrophobia.  After  the 
sick  room  has  been  emptied  in  all  cases  of  smallpox,  and  in  cases 
of  scarlatina  and  diphtheria,  when  specially  directed  by  the  police, 
the  floors,  walls,  windows  doors,  furniture,  &c,  must  be  rubbed 
with  cloths,  sponges,  or  brushes  dipped  in  the  solution  of  corrosive 
sublimate,  immediately  after  which  everything  which  can  be 
scraped  is  to  be  cleansed  with  the  potash  soap.  Upholstered  fur- 
niture, cushions,  mattresses,  curtains,  and  other  similar  articles 
which  cannot  be  washed,  are  to  be  disinfected  in  special  establish- 
ments by  the  use  of  dry  heat  or  super-heated  steam.  The  mat- 
tresses and  cushions  must  be  opened  for  this  purpose. 

"After  everything  in  the  room  has  been  treated  as  indicated, 
chlorine  gas  is  to  be  generated  in  the  room,  the  doors  and  windows 
being  closed  as  tightly  as  possible.  The  chlorine  is  generated  by 
pouring  hydrochloric  acid  upon  chloride  of  lime  in  equal  parts. 

"A  kilogramme  (2  lbs.  3  ozs.  119"8  grs.)  of  chloride  of  lime  is 
required  for  the  disinfection  of  an  average-sized  room.  To  prevent 
injury  to  metal  fixtures  which  cannot  be  removed,  they  are  to  be 


PREVENTIVE    TREATMENT,   OR    PROPHYLAXIS.  37 

covered  with  a  coat  of  oil  or  of  varnish.  The  apartment  is  to  be 
kept  closed  for  twelve  hours,  at  the  end  of  which  time  the  chlorine 
which  does  not  pass  out  sufficiently  rapidly  by  the  windows  may  be 
absorbed  by  cloths  dipped  in  ammonia." 

In  a  paper a  read  in  the  Section  of  Bacteriology  at  the  Seventh 
International  Congress  of  Hygiene  and  Demography,  held  in  London 
in  August,  1891,  Stabsarzt  Dr.  Behring,  of  Berlin,  said  that  recent 
researches  on  tetanus,  diphtheria,  anthrax,  and  such  like  diseases, 
had  shown  that  it  is  possible,  even  within  the  body,  to  combat  success- 
fully the  various  specific  poisons  produced  in  these  diseases.  In 
short,  we  have  now  got  so  far  as  to  be  able  to  speak  of  a  "disinfection 
within  the  body."  There  are  four  possible  ways  in  which  it  is  con- 
ceivable that  this  internal  disinfection  may  be  effected  :  — 

1.  By  killing  the  disease-producing  germs. 

2.  By  hindering  their  growth. 

3.  By  counteracting  their  disease-producing  properties — patho- 
genic organisms  losing  their  power  to  produce  poisonous  products. 

4.  By  antagonising  the  action  of,  or  destroying  altogether  the 
various  toxic  products  produced  by  the  bacteria. 

It  is  possible  that  the  disinfecting  action  may  be  exercised,  not 
directly  on  the  toxic  products,  but  indirectly  on  the  cells  of  the 
body,  and  that  the  beneficial  result  may  be  due  not  so  much  to  a 
destruction  of  the  toxic  products  as  to  an  increased  resisting  power 
conferred  on  the  cells  of  the  body,  in  virtue  of  which  they  are 
able  to  withstand  the  action  of  these  products.  This  last  mechanism 
of  disinfection  is  not  proved,  while  concrete  examples  can  be  brought 
forward  to  prove  the  occurrence  of  the  four  other  methods. 

As  an  example  of  disinfection  within  the  body,  Dr.  Behrino- 
shows  that  in  the  case  of  anthrax  being  inoculated  in  a  mouse,  the 
fatal  result  may  be  postponed  or  altogether  prevented  by  subsequent 
injection  of  0*4  cubic  centimetre  of  a  mixture  of  corrosive  sublimate 
(one  part  of  a  O04  per  cent,  solution)  and  chloroborate  of  sodium 
(three  parts  of  a  10  per  cent,  solution). 

These  and  such  like  observations  are  full  of  interest  and  bright 
with  promise  of  great  results  in  the  not  distant  future. 

"  Brit.  Med.  Journal,  August  22,  1891.     Pages  406,  et  seq. 


38  GENERAL   PRINCIPLES   OF  TREATMENT. 

The  139th  section  of  the  Public  Health  (Ireland)  Act,  1878  (41 
&  42  Vict.,  cap.  52),  authorises  every  sanitary  authority,  whether 
urban  or  rural,  to  "  provide  a  proper  place,  with  all  necessary 
apparatus  and  attendance,  for  the  disinfection  of  bedding,  clothing, 
or  other  articles  which  have  become  infected,"  and  to  cause  any 
articles  brought  for  disinfection  to  be  disinfected  free  of  charge. 
The  sanitary  authority  also  "  may  provide  for  the  conveyance  of 
such  articles  to  such  place." 

II.  We  have,  in  the  next  place,  to  consider  what  measures  should 
be  adopted  with  the  view  of  lessening  the  receptivity  of  an  indivi- 
dual  when   exposed  to   the   virus  of  one   of  the   specific  fevers. 
Regarding  the  introduction  of  that  virus,  or  morbific  agent,  into 
the  body  as  in  each  case  the  exciting  cause  of  the  specific  disease 
in  question,  we  find  that  one  or  more  predisposing  causes  usually 
co-exist  when  an  individual  contracts  that  disease.    Two  things  are, 
in  fact,  required — first,  an  infecting  morbific  agent,  virus,  or  con- 
tagium ;    and,   secondly,    a   state    of   the    body    which   renders   it 
peculiarly  liable  to  be  affected  injuriously  by  that  morbific  agent. 
It  is  this  latter  which  constitutes  predisposition  to  disease.    As  Dr. 
William  B.  Carpenter  points  out,a  any  habitual  infraction  of  the 
laws  of  health  will  induce  a  general  liability  to  disease,  by  pro- 
ducing a  depressed  condition  of  the   vital  activity,  whereby  the 
organism   is   rendered  less   capable  of  resisting   the  influence    of 
morbific  agents.     In  this  way  acquired  predisposition  is  brought 
about,  as  distinguished  from  hereditary  predisposition  to  disease, 
which  seems  to  follow  the  same  modified  laws  of  heredity  as  the 
transmission  of  family  peculiarities. 

The  chief  predisposing  causes  of  febrile  disorders  may  be  enume- 
rated as  follows : — 

1.  The  presence  of  an  antecedent  disease,  which  interferes  with 
the  excretory  organs,  by  which  the  effete  and  waste  matters  circu- 
lating in  the  blood  are  eliminated  and  cast  forth  from  the  body. 
To  enable  an  individual  to  resist  the  poison  of  typhus,  or  typhoid, 
or  scarlatina,  for  example,  the  great  emunctories — the  lungs,  the 

a  Quain's  Dictionary  of  Medicine.     Art.  Predisposition  to  Biaease.     London: 
Longmans,  Green,  &  Co.     1883.     Page  1,252. 


PREVENTIVE    TREATMENT,    OR    PROPnYLAXLS.  39 

liver,  the  intestinal  glands,  the  kidneys,  and  the  skin,  must  all  be 
sound  and  able  for  their  work. 

2.  The  introduction  into  the  body  of  putrescent  organic 
matter  in  either  food,  or  water,  or  air,  will  certainly  render  a 
person  more  susceptible  to  a  specific  poison  like  that  of  scarlatina 
or  cholera. 

3.  An  excessive  generation  of  effete  matter  within  the  body, 
as  during  the  puerperal  state,  or  after  severe  surgical  injuries  or 
operations,  will  have  a  like  effect  in  the  case  of  the  poisons  of 
scarlatina  and  erysipelas. 

4.  Excessive  exertion  of  mind  or  body,  marked  by  the  feeling 
of  fatigue,  has  always  ranked  as  a  most  potent  predisponent,  for 
example,  to  typhus  fever. 

5.  Overcrowding  and  defective  ventilation  are  amongst  the 
most  powerful  predisposing  causes  of  typhus.  "  All  the  historians 
of  the  great  epidemics  of  typhus,"  wrote  Murchison,a  "  testify  to  the 
intimate  connection  between  its  prevalence  and  overcrowding." 

6.  Alcoholic  Intemperance  induces  a  strong  predisposition  to 
zymotic  disease.  As  Murchison  admirably  puts  it  b  : — "Habitual 
intemperance  deranges  digestion,  impairs  nutrition,  causes  degene- 
ration of  the  excreting  organs,  retards  the  elimination  of  carbonic 
acid  and  urea,  and  lowers  the  tone  of  the  nervous  system."  "  It  is 
not  surprising,"  he  adds,  "  that  under  such  circumstances  the  body 
becomes  more  susceptible  of  the  poison  of  typhus." 

7.  Lastly,  it  is  unnecessary  to  enlarge  on  the  intimate  connection 
which  at  all  times  and  in  all  places  has  existed  between  Famine 
and  Pestilence.  Murchison  saysc:  "Destitution  and  deficient  ali- 
mentation are  the  most  powerful  predisposing  causes  of  typhus." 
As  to  relapsing  fever,  the  same  author  observes d  that  some  of  the 
appellations  bestowed  upon  it  in  different  countries  indicate  the 
popular  opinion  as  to  its  origin."  It  is  essentially  the  Famine  Fever 
of  the  British  Isle3,  and  the  A  rmentyphus  and  Hungerpest  of  Germany. 

*  A   Treatise  on  the  Continued  Fevers  of  Great   Britain.      Third   Edition. 
1884.     Page  72. 
b  Loe.  cit.     Page  70. 
e  Loc.  cit.     Page  73. 
d  Loc.  cit.     Page  341. 


40  GENERAL    PRINCIPLES    OF    TREATMENT. 

Dr.  William  B.  Carpenter,  having  regard  to  the  fact  that  the 
presence  of  nitrogenous  matter  in  a  decomposing  or  readily-decom- 
posable state  affords  the  best  possible  pabulum,  either  for  the 
development  of  pathogenic  micro-organisms,  or  for  the  action  of 
ferments,  as  long  ago  as  1853a,  came  to  the  conclusion  that  the 
common  condition  which  all  the  predisposing  agencies  just  men- 
tioned tend  to  produce  is  the  presence  in  the  blood  of  an  excess  of 
those  decomposing  effete  matters  with  which  the  circulating 
current  is  normally  charged  to  a  limited  extent.  Should  an  indi- 
vidual, with  his  blood  in  such  a  condition,  become  the  host  of  a 
pathogenic  microbe,  it  goes  without  saying  that  his  guest  will 
batten  and  thrive,  be  fruitful  and  multiply  exceedingly,  with  the 
result  that  symptoms  of  the  special  disease  will  soon  declare  them- 
selves. 

The  preventive  measures  to  be  adopted,  so  far  as  an  individual 
is  concerned,  who  is  exposed  or  is  likely  to  be  exposed  to  the 
poison  of  one  of  the  micro-parasitic  or  specific  diseases,  are  the 
following : — 

1.  Close  attention  must  be  paid  to  the  general  health.  The 
presence  of  any  organic  disease  is  to  be  carefully  sought  for  and 
combated.  The  state  of  the  digestion,  of  the  bowels,  and  of  the 
kidneys,  should  be  looked  to.  The  skin  should  be  kept  in  healthy 
action  by  daily  thorough  ablutions  and  dry  rubbing,  as  well  as  by 
suitable  clothing.  Should  a  person's  circumstances  or  health  forbid 
a  daily  bath,  the  surface  of  the  body  may  be  washed  piecemeal 
with  luke-warm  water  and  soap — absolute  personal  cleanliness  is 
indispensable,  and  particularly  in  the  case  of  young  children.  Free 
Public  Baths  and  Wash-Houses  should  be  provided  in  all  large 
centres  of  population. 

2.  Wholesome,  plain  food,  an  abundant  supply  of  pure  water, 
and  fresh  air  ought,  in  a  civilised  community,  to  be  claimed  as  a 
birthright  by  every  man,  woman,  and  child.  In  a  recently-pub- 
lished work  on  "  Bacteria  and  their  Products,"1  Dr.  German  Sims 

a  The  Predisposing  Causes  of  Epidemics.  Brit,  and  For.  Med.  Chir.  Review. 
Vol.  XI.     Page  159,  et  seq. 

b  London  :  Walter  Scott.     1891.     Page  201. 


PREVENTIVE  TREATMENT,  OR  PROPHYLAXIS.     41 

Woodhead  observes: — "Dnclaux's  dictum  that  fresh  air  and  sun- 
light are  two  of  the  most  powerful  agents  that  we  have  with  which 
to  combat  the  onslaught  of  disease,  cannot  be  too  strongly  insisted 
on." 

Full  powers  are  given  to  sanitary  authorities  for  the  inspection 
of  food,  in  England  under  sections  1 1 6—1 19  of  the  Public  Health 
(England)  Act,  1875  ;  in  Scotland  under  Section  26  of  the  Public 
Health  (Scotland)  Act;  and  in  Ireland  under  sections  132-136  of 
the  Public  Health  (Ireland)  Act,  1878.  As  regards  water  supply, 
it  is  generally  conceded  that  30  gallons  of  pure  water  per  head  of 
the  population  should  be  provided,  if  health  is  to  be  maintained, 
especially  in  large  towns.  The  question  of  fresh  air  we  will  discuss 
later  on.  Defective  sewerage  arrangements  frequently  lead  to  con- 
tamination of  food,  drink,  and  air,  and  therefore  demand  immediate 
attention. 

3.  From  what  was  stated  above,  it  is  evident  that  the  strictest 
sanitary  precautions  should  be  taken  when  a  puerperal  woman  or 
a  wounded  person  is  exposed  to  the  poison  of  any  of  the  diseases 
we  are  considering. 

4.  "  Fatigue  of  mind  or  of  body,"  says  Murchison,a  "  is  to  be 
scrupulously  shunned  by  persons  who  are  necessarily  exposed  to 
the  poison  of  typhus."  And  this  is  equally  true  of  the  other 
infectious  fevers  also.  No  physician,  student  of  medicine,  or  nurse 
should  enter  a  fever-ward  tired,  or  after  a  sleepless  night.  Re- 
creation of  mind  and  body  at  stated  intervals  is  an  essential  pre- 
ventive measure  in  the  case  of  those  who  attend  fever  patients. 
Their  hours  for  sleep  should  be  ample  and  undisturbed.  They 
should  never  sleep  in  the  sick  room,  and  as  much  of  their  time  as 
possible  should  be  spent  in  the  open  air. 

5.  If  health  is  to  be  maintained,  whether  among  the  poor  or 
among  the  rich,  sufficient  cubical  air  space  and  free  ventilation  in 
the  dwelling  are  essential.  Adults  spoil  every  hour  about  5  cubic 
feet  of  air  (140  litres) — that  is,  they  render  5  cubic  feet  of  air 
absolutely  irrespirable.  But  600  times  that  amount  of  air — that 
is,  3,000  cubic  feet — will  be  required  to  keep  the  atmosphere  "in 

a  Loc.  cit.     Page  272. 


42  GENERAL   PRINCIPLES   OF   TREATMENT. 

the  highest  degree  of  practicable  purity."8.  In  practice,  it  is  found 
that  from  500  to  750  cubic  feet  of  air-space  per  head  are  required 
in  a  dwelling  room  ;  but,  in  addition,  2  cubic  feet  of  fresh  air  per 
head  should  be  admitted  into  the  room  every  minute.  This  latter 
indication  is  effected  by  constant  and  occasional  ventilation  or 
"  the  art  of  supplying,  without  perceptible  draught,  the  requisite 
quantity  of  pure  air."b  Happily  for  mankind,  it  is  not  possible  to 
hermetically  seal  a  dwellingroom — no  matter  how  rigorously 
windows  and  doors  are  closed,  air  leaves  such  a  room  by  the 
chimney  and  enters  it  by  various  chinks  and  crevices.  This  inter- 
change of  air,  which  is  beyond  control,  is  called  constant  or  natural 
ventilation.  The  more  decided  change  of  air,  which  is  called 
occasional  ventilation,  occurs  when  doors  and  windows  are  thrown 
open.  This  must  be  duly  regulated  so  as  to  avoid  a  draught, 
which  is  caused  when  air  at  a  temperature  between  55°  and  60°  J*\ 
streams  through  an  opening  at  a  greater  rate  than  two  miles  an 
hour,  that  is,  three  feet  per  second.  It  is  necessary  to  observe 
that  near  a  cold  surface,  such  as  a  damp  wall,  a  sensation  of 
"  draught,"  or  chilliness,  may  be  caused  even  when  the  air  is  almost 
still. 

"The  dwellings  of  the  poor,"  says  Murchison,0  "ought  to  be  so 
constructed  as  to  ensure  good  ventilation.  Closed  courts,  sur- 
rounded by  high  houses,  are  always  objectionable.  Every  window- 
frame  ought  to  be  movable,  and  every  room  should  be  provided 
with  means  for  constant  ventilation.  Human  beings  ought  to  be 
prohibited  from  living  in  underground  cellars,  where  proper  ven- 
tilation is  impossible." 

6.  Among  the  most  preventable  predisposing  causes  of  infectious 
disease  is  alcoholic  intemperance.  It  is  not  so  widely  known 
as  it  should  be  that  this  deadly  sin  not  only  strongly  predisposes 
to  these  diseases  but  also  materially  lessens  the  chance  of  recovery 
from  them.  The  vice  betrays  and  kills.  Let  us  once  more  hear 
Murchison  on   this  point : — "  There  is  no   greater  error  than  to 


a  A.  Wynter  Blyth.     Loc.  cit.     Page  63. 
b  A.  Wynter  Blyth. 
c  Loc  cit.     Page  269. 


PREVENTIVE  TREATMENT.  OR  PROPHYLAXIS.     43 

imagine  that  a  liberal  allowance  of  alcoholic   stimulants   fortifies 
the  system  against  contagious  diseases."* 

7.  "  The  prevention  of  scarcity  of  food,  loss  of  employment,  and 
other  causes  of  destitution,"  writes  the  same  great  physician,  "  is 
not  always  within  human  power;  but,  under  such  circumstances, 
every  means,  both  public  and  private,  calculated  to  alleviate  the 
distresses  of  the  poor  should  be  adopted.  Moreover,  no  time  is  to 
be  lost  in  affording  relief;  it  is  difficult  to  stay  the  plague  when 
once  it  has  begun.  Care  also  must  be  taken  that  the  funds  col- 
lected for  such  purposes  do  not  produce  the  very  evils  they  are 
intended  to  avert.  The  poor  naturally  flock  in  greater  numbers  to 
those  localities  where  most  relief  is  to  be  obtained,  and  the  result 
has  often  been  increased  crowding.  The  expediency  of  supplying 
relief  to  the  poor  in  their  crowded  dwellings  may,  therefore,  be 
questioned.  A  preferable  plan  would  be  to  establish,  during 
seasons  of  scarcity  and  when  typhus  is  prevalent,  temporary 
buildings  of  wood  or  iron,  or  tents,  in  the  neighbourhood  of  large 
towns.  Here  overcrowding  could  be  prevented,  the  poor  could  be 
supplied  with  abundance  of  fresh  air  and  food,  while  the  number 
of  persons  resorting  thither  for  relief  would  prevent  overcrowding 
in  the  towns.  The  expense  of  such  a  plan  would  certainly  not 
exceed  what  the  spread  of  an  epidemic  always  entails."b 

8.  To  this  branch  of  the  subject  of  prophylaxis  belongs  also  the 
procedure  commonly  called  "  inoculation,"  the  intention  of  which  is 
to  engraft  in  a  healthy  individual — whose  receptivity  in  consequence 
would  be  low — a  mild  form  of  a  particular  infectious  disease  by 
means  of  an  attenuated  virus  of  that  disease. 

III.  The  third  great  means  at  our  disposal  in  the  attempt  to 
check  the  spread  of  one  of  the  infectious  fevers  is  the  strict  enforce- 
ment of  quarantine  (using  the  term  in  its  modern  acceptation),0 
and  of  isolation. 

1.  In  Table  I.,  p.  29,  under  the  heading,  "  Quarantine,"  the  time 
is  specified  during  which  possibly  infected  persons  should  be  segre- 
gated, or  kept  apart,  so  as  to  secure  that  they  shall  not  do  further 

a  Loc  cit.     Page  70. 
b  Loc  cit.     Page  269. 
0  See  above.     Page  27. 


44  GENERAL    PRINCIPLES    OF    TREATMENT. 

mischief  by  spreading  infection  should  they  themselves  develop 
symptoms  of  disease.  This  risk  is  vastly  increased  in  the  case  of 
a  malady  like  measles,  which  is  infectious,  or  "  taking,"  from  the 
first  sneeze  which  the  patient  gives. 

In  private  families,  or  those  occupying  the  whole  of  one  house, 
it  will  suffice  that  the  member  or  members  of  the  household  sus- 
pected to  have  contracted  a  disease  shall  be  kept  apart  from  the 
rest  of  the  family  until  such  time  as  the  incubation  period  of  the 
particular  disease  shall  have  passed  by  without  the  development  of 
suspicious  symptoms. 

Refuges  for  persons  removed  from  infected  tenement  houses 
should  be  provided  in  every  town  where  a  number  of  families 
reside  under  one  roof,  in  order  to  stay  the  spread  of  an  epidemic. 
The  sick,  in  such  a  case,  should  at  once  be  removed  to  hospital, 
and  the  healthy  to  a  refuge  where  they  could  be  watched  for  the 
outbreak  of  further  cases.  In  this  way  the  infected  house  could 
be  conveniently  cleansed  and  disinfected.  The  Refuge  should  be 
arranged  in  sets  of  rooms,  or  "  flats,"  as  they  are  called  in  Scot- 
land— so  that  each  family  might  keep  together.  This  would  not 
only  ensure  the  comfort  of  the  family,  but  also  limit  the  spread  of 
the  disease  to  the  particular  family  among  whom  it  arose. 

2.  When  a  member  of  a  private  family  is  proved,  or  even 
suspected,  to  be  suffering  under  an  infectious  or  "  taking  "  disease, 
he  should  be  isolated,  preferably  in  a  separate  building,  or,  failing 
this,  in  an  airy  room  at  the  top  of  the  house.  Outside  the  door  of 
the  sick  chamber  a  sheet  should  be  hung,  and  kept  saturated  with 
some  liquid  volatile  disinfectant,  like  carbolic  acid,  sanitas,  or 
chloride  of  lime.  The  room  should  be  large,  well  ventilated,  but 
warm  (temperature  about  60°  Fahr),  well  lighted.  It  should  contain 
an  open  fire-place.  To  secure  ample  air  space,  as  well  as  to  lessen 
the  risk  of  infection  through  fomites,  or  "  carriers  of  infection," 
all  bed- curtains,  carpets,  and  non-essential  articles  of  furniture 
should  be  removed.  Tlie  patient's  surroundings  should  be  kept 
scrupulously  clean  and  pure;  soiled  linen  and  crockery  should  not 
be  taken  out  of  the  sick  room  until  they  have  been  dipped  in  a 
disinfecting  solution — carbolic  acid,  benzoic  acid,  sanitas,  Condy's 


PREVENTIVE  TREATMENT,  OR  PROPHYLAXIS.      45 

fluid,  or  corrosive  sublimate.  The  sick  room  may  be  sprayed  with 
sanitas  solution  several  times  a  day,  or  one  of  the  "disinfecting 
cones,"  supplied  by  the  Chemical  Carbon  Company,  may  be  burned 
from  time  to  time. 

Among  the  poorer  classes  isolation — important  and  theoretically 
simple  a  plan  as  it  is  for  the  prevention  of  the  spread  of  infections 
diseases — is  with  difficulty  carried  out.  The  means  employed  for 
the  purpose  are — (1)  the  early  removal  of  the  sick  to  hospital  in  a 
properly  constructed  ambulance ;  (2)  his  admissTon,  first  to  a 
reception-room,  where  his  own  clothes  should  be  taken  off,  dis- 
infected if  necessary,  and  then  removed  to  a  proper  store-room, 
and  where  the  patient  himself  should  be  washed  and  made  tidy 
before  he  is  placed  in  bed  in  a  suitable,  airy,  well-ventilated  and 
properly  heated  ward ;  (3)  his  treatment  in  such  a  ward,  reserved 
absolutely  for  cases  of  the  disease  from  which  he  is  suffering,  visitors 
being  forbidden  admission  except  under  the  most  pressing  and 
urgent  circumstances ;  and  (4)  lastly,  his  removal  in  due  time  to  a 
Convalescent  Home,  where  he  may  gain  health  and  strength  before 
he  returns  to  his  work. 

The  treatment  of  the  infectious  fevers  in  the  wards  of  General  or 
Medico-Chirurgical  Hospitals,  should,  as  far  as  possible,  be  avoided, 
and  permanent  Epidemic  Hospitals  should  be  provided  by  every 
Sanitary  Authority,  the  accommodation  in  such  hospitals  being  at 
the  rate  of  one  bed  for  every  200  of  an  urban  population,  and  every 
400  of  a  rural  population. 

A  lengthened  experience  has  led  me  to  the  conclusion  that  the 
most  feasible  method  of  attempting  to  limit  the  spread  of  "  catching" 
or  "'  taking"  disease,  is  by  a  system  of  complete  isolation,  not  only 
of  the  sick,  but  also  of  the  convalescent.  The  convalescent  from 
an  infectious  disease  must  be  kept  separate  until  the  days  of  his 
purification  are  accomplished — in  the  words  of  the  Mosaic  Law  : — 
"  He  shall  dwell  alone  ;  without  the  camp  shall  his  habitation  be."a 
In  hospital  and  in  private  practice,  I  have  had  frequent 
opportunities  of  recognising  the  want  which  exists  of  suitable 
accommodation  for  infectious  convalescents.     Although  we  are  just 

a  Leviticus.     Chap,  xiii.,  v.  46. 


46  GENERAL   PRINCIPLES   OF   TREATMENT. 

now  primarily  concerned  with  the  protection  of  the  healthy  from 
the  risk  of  infection,  I  may  be  permitted  to  advance  four  reasons 
why,  in  the  interest  of  the  convalescents  themselves,  we  should 
provide  for  them  a  temporary  home  outside  the  hospital  precincts  : — 

1.  The  health  of  convalescents  is  often  seriously  injured  if  they 
are  kept  in  hospital  beyond  a  certain  period  in  their  progress 
towards  recovery. 

2.  The  surroundings  in  even  the  best-managed  epidemic  hospitals 
cannot  fail  to  exercise  a  depressing  influence  on  the  minds  of 
patients  who  are  recovering  from  illness. 

3.  It  should  not  be  forgotten  that  beds  are  being  occupied  by 
the  convalescent  which  may  perhaps  be  urgently  required  at  the 
very  moment  for  other  patients  in  the  earlier  stages  of  their  sickness. 

4.  Lastly,  it  is  most  desirable  that  those  who  toil  for  their  daily 
bread  should  not  leave  hospital  to  return  at  once  to  their  wonted 
employment.  It  frequently  has  happened  that  the  sudden  strain 
in  this  way  put  upon  the  bodily  powers  not  yet  recovered  from  a 
deadly  conflict  with  sickness  has  led  to  disastrous  results — in  some 
instances  the  seeds  of  permanent  organic  disease  have  been  thereby 
sown. 

Patients  in  private  practice  also,  equally  with  hospital  patients, 
require  "  change  of  air "  after  an  illness,  and  provision  should  be 
made  for  them  in  separate  rooms  in  a  Convalescent  Home  for 
Infectious  Diseases. 

So  far  as  to  the  patients  themselves.  No  one  will  need  to  be 
told  how  imperative  it  is  in  the  interest  of  the  public  health  that 
the  convalescent  from  infectious  maladies  should  be  kept  apart 
from  the  healthy  until  all  risk  of  infection  is  over.  This  applies 
not  less  to  private  than  to  hospital  patients.  How  can  the  needful 
isolation  be  kept  up  except  through  the  medium  of  Convalescent 
Homes  ? 

The  Law  is  on  my  side  in  my  advocacy  of  the  means  of  isolation 
now  indicated.  Take,  for  example,  the  "  Public  Health  (Ireland) 
Act,  1878."  Section  140  requires  (it  is  compulsory)  that  "every 
sanitary  authority  shall  provide  and  maintain  a  carriage  or  carriages 
suitable  for  the  conveyance  of  persons  suffering  under  any  infectious 


PREVENTIVE  TREATMENT,  OR  PROPHYLAXIS.      47 

disorder,  and  shall  pay  the  expense  of  conveying  therein  any  person 
so  suffering  to  a  hospital  or  other  place  of  destination,  and  shall 
keep  such  carriage  or  carriages  properly  disinfected."  Can  any 
legal  document  be  more  explicit  than  this  ? 

Section  141  of  the  same  Act  of  Parliament  provides  for  the 
removal  of  infected  persons  without  proper  lodging  to  hospital  by 
order  of  any  Justice  of  the  Peace.  Section  142  imposes  a  penalty 
on  exposure  of  infected  persons  and  things.  Under  Sub-section  5 
of  this  Section,  in  the  Northern  Divisional  Police  Court,  Dublin, 
on  Saturday,  July  12,  1879,  before  Mr.  C.  J.  O'Donel,  a  man 
was  fined  £5 — the  full  penalty — for  permitting  a  "  wake  "  to  be 
held  in  his  room  in  a  tenement  house  in  Church-street,  Dublin,  on 
the  body  of  his  son,  who  died  of  confluent  smallpox  on  the  10th 
of  the  previous  month.  Section  143  imposes  a  penalty  on  failing 
to  provide  for  the  disinfection  of  a  public  conveyance.  In  the 
same  Police  Court  as  before,  on  Saturday,  February  21,  1880,  the 
same  Magistrate  fined  the  driver  of  a  hackney  car  £5 — the  full 
penalty — for  failing  to  have  his  car  disinfected  after  conveying  a 
smallpox  patient  on  it  to  the  Hardwicke  Fever  Hospital,  Dublin, 
on  February  5. 

Section  155  empowers  any  Sanitary  Authority  (whether  urban 
or  rural),  with  the  sanction  of  the  Local  Government  Board,  to 
provide  for  the  use  of  the  inhabitants  of  its  district,  "  hospitals  or 
temporary  places  for  the  reception  of  the  sick  or  convalescent."  These 
are  the  very  words  of  the  section,  and  nothing  can  be  more  definite 
or  comprehensive  than  they  are.  The  section  requires  amendment 
only  so  far  as  it  does  not  contemplate  or  authorise  the  provision 
of  refuges  for  those  still  healthy  who  have  been  removed  from 
infected  dwellings. 

To  sum  up— the  Prophylaxis,  or  Preventive  Treatment  of 
acute  specific  infectious  disorders  consists  in — 

1.  Disinfection; 

2.  The  removal  or  neutralisation  of  the  Predisposing  Causes 

of  this  class  of  diseases ; 

3.  The  strict  enforcement  of  Quarantine  and  of  Isolation. 


48 


CHAPTER  V. 

The  General  Principles  of  Treatment  of  the 
Eruptive  and  Continued  Fevers. 

Part  II. — Curative  Treatment. 

Principles  of  Treatment  of  Fevers. — 1.  To  neutralise  the  Fever  Poison: 
sanitary  surroundings,  mineral  acids,  antiseptics. — 2.  To  promote  elimination  : 
fresh  air,  diluents,  diuretics,  diaphoretics,  aperients  or  laxatives,  beneficial 
effects  of  common  salt  (chloride  of  sodium). — 3.  To  reduce  temperature  : 
hygienic  measures — bloodletting  (general  or  IochI),  saline  cathartics,  diaphoretics, 
antipyretics  (Cantani's  Views  on  Antipyresis)  ;  hydriatic  measures — tepid 
sponging,  the  wet-pack,  the  application  of  ice-cold  compresses,  the  cold  bath, 
the  ice-cradle  (Fen  wick).— 4.  To  maintain  nutrition:  food  to  be  both  nutri- 
tious and  digestible,  peptonised  food,  times  for  feeding  the  fever  patient, 
feeding  through  the  nares  or  by  the  rectum  ;  administration  of  alcoholic 
stimulants — indications  for  their  use,  signs  of  their  agreeing  with  the  patient, 
avoidance  of  exhaustion. — 5.  To  relieve  distressing  symptoms  :  headache, 
sleeplessness,  nervous  excitement,  delirium,  stupor,  convulsions,  hyperaesthesia, 
rheumatoid  and  neuralgic  pains,  thirst,  persistent  vomiting,  tymp-inites  or 
meteorism,  hiccough,  diarrhoea,  intestinal  haemorrhage. — 6.  To  obviate  and 
counteract  local  complications  and  sequelae. 

If  we  bear  in  mind  the  bacterial  origin — proved  in  some  cases, 
inferred  by  analogy  in  others — of  the  diseases  we  are  considering, 
their  clinical  history,  and  the  pathological  appearances  they  present, 
we  may  with  Murchison  lay  down  the  following  Principles  of 
Treatment :  — 

1.  To  neutralise  the  fever  poison  and  improve  the  state  of  the 

blood. 

2.  To  promote  elimination,  not  merely  of  the  fever  poison,  but 

also  of  the  products  of  tissue-change,  or  metamorphosis. 

3.  To  reduce  temperature  and  to  lessen  the  frequency  of  the 

heart's  action. 

4.  To  maintain  the  nutrition  of  the  body  and  to  stimulate  when 

necessary  the  heart's  action  by  food  and  stimulants. 


CURATIVE    TREATMENT.  49 

5.  To  relieve  distressing  symptoms  as  they  arise — such  as  head- 

ache, sleeplessness,  pain,  restlessness,  prostration,  stupor, 
delirium,  cough,  constipation,  diarrhoea,  thirst,  and  so  on. 

6.  To  obviate  and  counteract  local  complications,  or  those 

secondary  affections  which  intervene  in  the  course  of  the 
primary  malady,  upsetting  its  normal  course  and  imperil- 
ling the  patient's  life,  or  prolonging  the  fever  movement 
to  a  greater  or  less  extent. 

It  will  be  necessary  to  consider  each  of  these  indications  for 
treatment  in  some  detail : — 

1.  The  sanitary  surroundings  of  a  patient  suffering  under  a 
specific  fever  should  be  above  suspicion.  In  the  previous  chapter 
we  have  already  dealt  with  this  topic  at  some  length  from  the 
standpoint  of  Preventive  Medicine,  and  it  is  a  happy  reflection 
that  all  the  measures  we  take  to  arrest  the  spread  of  infection  from 
the  sick  chamber  will  also  directly  benefit  its  stricken  tenant  for 
the  time  being.  Fresh  air  and  warmth  and  daylight  are  magical 
remedies  in  disease.  The  darkened  sick  room  is  a  mistake,  except 
perhaps  in  meningitis  or  measles,  or  when  the  patient  complains 
that  light  hurts  his  eyes  (photophobia).  A  patient  will  sleep 
better  by  night  in  a  room  where  a  broad  difference  between  day 
and  night  has  been  made.  Of  one  thing  we  may  be  perfectly  sure, 
that  it  is  madness  to  treat  a  typhoid  fever  patient  in  the  house 
where  he  has  contracted  his  illness,  with  its  tainted  atmosphere  and 
its  probably  poisoned  water  supply.  Nothing  is  more  striking  than 
the  marvellous  improvement  which  often  follows  a  fever  patient's 
removal  to  an  airy,  well-warmed,  wholesome  ward  of  a  hospital. 

Among  drugs  which  tend  to  fulfil  the  first  object  we  set  before 
us  in  treating  febrile  diseases,  the  various  so-called  "mineral  acids" 
enjoy  a  well-established  and  classical  reputation.  Probably  the 
most  useful  of  all  is  the  dilute  hydrochloric  acid.a  In  cases  where 
the  bowels  are  loose,  dilute  sulphuric  acid  or  the  aromatic  sulphuric 

n  "  Half  a  drachm  of  the  dilute  acid  with  a  like  quantity  of  the  tincture  and 
syrup  of  orange  may  be  given  in  solution  every  three  hours.'' — Murchison. 
Treatise  on  the  Continued  Fevers  of  Great  Britain.     Page  274. 

E 


50  GENERAL   PRINCIPLES    OF   TREATMENT. 

acid  may  be  substituted  with  advantage.  Dilute  nitric  and  phos- 
phoric acids  also  come  under  the  same  heading.  They  may  be 
combined  with  antiseptics  like  quinine  or  ferric  chloride,  or  with 
cardiac  tonics  like  digitalis  or  nux  vomica,  or  with  nervine  tonics  like 
strychnin  or  hydrochloric  solution  of  arsenic. 

Antiseptics  are  prescribed  to  meet  the  same  indication.  Those 
chiefly  in  use  are  carbolic  acid,  sulphurous  acid,  sulphite  of  sodium, 
the  sulpho-carbolates  (which  enjoyed  a  considerable  reputation  in 
the  last  two  epidemics  of  small-pox  in  Dublin),  bismuth,  salicylate 
of  sodium,  chlorate  of  potassium,  permanganate  of  potassium,  and — ; 
facile  princeps — quinine.  Inhalation  of  oxygen  is  well  worth  a  trial 
as  a  blood  purifier  in  septic  fevers  with  impaired  lung-action  and 
cyanosis. 

It  may,  perhaps,  be  necessary  to  explain  that,  in  the  words  of 
Dr.  J.  Burney  Yeo,a  "  the  idea  of  an  antiseptic  treatment  of  certain 
forms  of  disease  has  been  greatly  misunderstood  or  intentionally 
misrepresented  by  those  who  for  some  inscrutable  reason  dislike  it; 
and  those  of  us  who  have  been  bold  enough  to  entertain  this  idea 
have  been  credited  with  the  crude  intention  of  attempting  to  slay 
these  parasitic  morbific  agents  'in  a  direct  and  simple  manner,' 
and  we  have  been  gravely  told  that  our  so-called  antiseptic  methods 
are  so  murderous  that  our  patients  and  not  the  microbes  fall  victims 
to  them."  Dr.  Yeo  shows  that  every  analogy  in  nature  points  to 
the  possibility  of  effectually  modifying  the  life-history  and  activities 
of  all  living  things  by  even  slight  modifications  of  their  environ- 
ment. The  real  aim  of  the  antiseptic  treatment  of  the  infective 
diseases  is  to  modify  or  counteract  the  injurious  activities  of  the 
living  parasitic  agents  of  these  diseases.  Antiseptic  methods,  too, 
may  act  either  by  preventing  the  formation  of  the  poisonous 
animal  alkaloids,  or  ptomai'ns,  to  which  pathogenic  microbes  seem, 
or  are  believed,  to  give  rise,  or  by  destroying  these  ptoma'ins 
when  formed,  or,  lastly,  by  promoting  their  discharge  from  the 
body. 

a  The  Treatment  of  Typhoid  Fever,  especially   by   "  Antiseptic "   Remedies. 
London.  :  Cassell  &  Co.     1891.     Pages  5-8. 


CURATIVE    TREATMENT.  51 

2.  In  attempting  to  meet  the  second  indication  of  restoring  or 
increasing  the  eliminative  power  of  the  various  organs  which  are 
commonly  called  the  "  great  emunctories,"  we  rely  on  fresh  air, 
diluents  (of  which  the  best  and  safest  is  pure  cold  water),  diuretics, 
salines,  diaphoretics,  emetics  (now  very  seldom  employed  except, 
perhaps,  in  the  early  stage  of  typhoid  fever),  and  simple  purgatives 
or  laxatives. 

The  fever  patient  is  fastidious  in  his  choice  of  drinks,  but  he  may 
be  allowed  to  partake  freely  of  such  liquids  as  water,  iced  water, 
toast  water,  barley  water,  raspberry  vinegar,  well-diluted  lemon- 
juice,  or  the  juice  of  oranges  when  in  season.  Soda-water  and  milk 
or  seltzer-water  and  milk  make  a  nutritious  beverage.  All  the<e 
diluents  should  be  taken  in  moderate  quantities  at  a  time,  so  as  not 
to  distend  the  stomach  and  so  cause  discomfort. 

The  diuretics  employed  should,  as  far  as  possible,  be  non- 
stimulating,  such  as  digitalis,  nitre-whey  (prepared  by  boiling  two 
drachms  of  nitrate  of  potassium  in  a  pint  of  milk  and  straining), 
potus  imperialis  (prepared  by  dissolving  60  to  120  grains  of  acid 
tartrate  of  potassium — "cream  of  tartar" — in  a  pint  of  boiling 
water  and  flavouring  with  lemon  and  sugar),  tea  and  coffee,  citrate 
of  caffein,  or,  better  still,  "  dhiretin,"  (sodio-theobromin  salicylate) 
given  in  15  grain  doses  thrice  a  day  in  mixture  with  peppermint 
water  and  syrup. 

Diaphoretics  are  not  often  employed  at  the  present  day  in  the 
treatment  of  fever,  and  scarcely  ever  should  be  given  after  the  first 
few  days  of  illness.  Common  nitre,  and  spirit  of  nitrous  ether  are 
those  probably  most  frequently  used.  But  as  a  rule  it  will  be 
found  that  tepid  sponging  from  time  to  time  will  keep  the  skin 
acting  sufficiently. 

Throughout  an  attack  of  fever,  it  is  desirable  that  the  bowels 
should  act  regularly,  but  only  mild  methods  should  be  adopted  to 
secure  the  end  in  view.  Very  often  copious  draughts  of  water  alone 
will  suffice  ;  a  glycerine  enema  or  suppository  may  be  used  (except 
in  typhoid  fever,  when  a  simple  enema  will  be  safer)  ;  a  small  dose 
of  calomel  (I  to  5  grains)  with  sugar  of  milk  or  rhubarb  powder 
(except  in  scarlet  fever)  ;  a  teaspoonful  of  castor  oil  with  one  of 


52  GENERAL,    PRINCIPLES    OF   TREATMENT. 

glycerine  in  milk,  repeated  every  6  or  8  hours  if  necessary ;  or  a 
dose  of  the  new  "  Mistura  Olei  Ricini "  of  the  British  Pharma- 
copoeia— these  are  all  safe  aperients  or  laxatives.  Young  children 
bear  a  dose  of  calomel — 1  to  3  grains— uncommonly  well,  and  it 
usually  has  an  excellent  effect. 

The  good  effects  of  giving  common  salt — "  chloride  of  sodium  " — 
in  fever  are  possibly  due  to  its  antiseptic  properties  and  to  its  property 
of  increasing  elimination.  Murchison  used  to  order  large  quantities 
of  salt  to  be  mixed  with  the  patient's  beef  tea,  and  found  it  in  most 
cases  greatly  relished  and  apparently  beneficial. 

3.  The  third  indication  for  treatment — namely,  the  reduction  of 
temperature — may  be  met  in  the  first  place  by  the  adoption  of  the 
hygienic  measures  already  described.  The  patient  should  lie  on  a 
hair-mattress,  or  a  woven  wire-mattress,  covered  with  a  moderate 
quantity  of  bed-clothes.  The  temperature  of  the  sick  room  should 
not  much  exceed  60°  F. 

Bloodletting,  whether  general  (venesection)  or  local  (leeching  or 
wet  cupping),  was,  in  days  gone  by,  a  favourite  means  of  reducing 
temperature,  and  to  the  present  day  the  fall  of  temperature  which 
accompanies  an  intestinal  haemorrhage  in  typhoid  fever  seems  to 
warrant  the  adoption  of  this  mode  of  treatment  in  hyperpyrexia, 
or  excessive  fever.  But  in  practice,  bloodletting  is  found  to  be  far 
too  depressing  to  be  safe,  except  in  rare  instances.  For  example, 
in  certain  cases  of  acute  pneumonic  fever,  venesection  occasionally 
certainly  saves  life,  and  local  depletion  by  leeching  or  wet  cupping 
relieves  the  early  headache  of  typhus  or  smallpox,  lessens  the  amount 
of  eruption  in  the  latter  disease,  and  restores  kidney  action  in  the 
nephritis  of  scarlatina. 

Saline  cathartics  or  diaphoretics  are  sometimes  employed  to 
reduce  temperature,  but  these  classes  of  remedies  are  inadmissable 
when  we  have  to  deal  with  a  failing  heart.  We  then  resort  to  the 
so-called  antipyretics,  of  which  quinine,  digitalis,  acetanilide 
(antifebrin),  phenacetin,  and  phenazone  (antipyrin)  are  the  most 
striking  representatives.  If  acetanilide  and  phenazone  are  given 
in  large   doses — 10  to  20  grains— they  are  apt  to  cause  cardiac 


CURATIVE    TREATMENT.  53 

depression  and  even  cyanosis,  but  this  objection  does  not  hold  good 
in  the  case  of  phenacetin.  Even  3  to  5  grains  of  phenazone  have 
produced  very  unpleasant  effects  in  a  child. 

In  Cantani's  Address  on  "  Antipyresis "  to  the  Tenth  Inter- 
national Medical  Congress  at  Berlin,  to  which  I  have  before 
referred,  he  says  that  the  proper  remedies  for  fever  would  be  such 
as  act  on  the  cause  of  the  disease.  In  this  way  quiuine  acts  in 
malaria,  mercury  in  syphilis.  The  antipyretic  remedies — as  anti- 
pyrin  (phenazone) — have  no  special  action  on  the  causes  of  fever. 
They  lower  temperature  by  increasing  radiation  of  heat  from  the 
body,  and  they  diminish  heat-production.  They  do  harm  by  in- 
terrupting the  course  of  the  fever,  diminishing  the  means  of  defence 
of  the  human  organism,  for  a  diminution  in  the  production  of  heat 
is  equivalent  to  a  diminution  of  the  vitality  of  the  human  organism 
and  of  its  power  of  resistance.  In  excessive  fever  (hyperpyrexia), 
however,  the  cardiac  muscle  and  the  nervous  system  suffer;  and 
under  these  circumstances,  a  reduction  of  temperature  is  desirable^ 
if,  by  abstraction  of  heat,  heat  production  is  not  diminished.  The 
"  cold  water  treatment "  {die  hydriatiache  Wdrme-entziehung),  by 
cold  baths,  the  cold  pack,  cold  douches,  the  internal  administration 
of  large  quantities  of  cold  water,  either  by  the  mouth  or  by  enema, 
act  in  this  way.  They  absorb  a  large  amount  of  heat  from  the 
body,  whilst  they  rather  augment  the  formation  of  heat.  It  is  not 
known  if  the  good  effects  which  these  remedies  produce  are  due  to 
increased  tissue  waste  and  elimination  of  excrementitious  matters, 
including  ptomai'ns  and  leucomai'ns.  Certain  diseases,  attended  with 
high  temperature,  are  often  successfully  treated  with  diaphoretics, 
which  cause  an  increased  excretion  of  noxious  matters,  but  which 
scarcely — if  at  all — increase  heat  production. 

Cantania  holds  that  for  certain  fevers  there  are  specific  remedies, 
which  attack  the  cause  of  the  disease  itself.  There  are,  howrever, 
no  general  antipyretics.  The  most  that  can  be  done  is  to  diminish 
the  accumulation  of  heat  in  the  febrile  body  without  lowering  the 
production  of  heat.     To  effect  this,  the  cold  water  treatment  can 

a  See  abstract  of  Cantani's  Address  in  Sajous'  Annual  of  the  Universal  Medical 
Sciences  for  1891.     VoL  I.,  Pages  34-36. 


54  GENERAL.  PRINCIPLES    OF   TREATMENT. 

be  recommended,  whilst  the  chemical  antipyretics  must  be  looked 
upon  with  suspicion  as  general  remedies  for  fever. 

"  The  application  of  cold  water  to  the  surface  of  the  body," 
says  Dr.  SamUel  Fenwick,a  "  is  the  most  certain  means  of  reducing 
an  elevated  temperature,  and  there  are  various  methods  of  employ- 
ing this  measure,  each  of  which  is  specially  adapted  for  particular 
cases.  The  chief  of  these  are  sponging,  the  wet-pack,  the  application 
of  cloths  wet  in  ice-cold  water,  the  cold-bath,  and  the  ice-cradle.''' 

Tepid  sponging  is  most  grateful  and  refreshing,  and  reduces  the 
temperature  of  the  surface  about  1^°  or  2°  F.  To  carry  it  out,  the 
patient  is  laid  on  a  folded  blanket  and  the  surface  of  the  body  is 
thoroughly  mopped  with  a  sponge  squeezed  out  of  tepid  or  warm 
water,  to  which  a  varying  proportion  of  vinegar  or  aromatic  vinegar 
has  been  added.  The  sponging  may  be  continued  for  10  or  15 
minutes  and  renewed  twice  or  three  times  in  the  24  hours.  The 
wet-pack,  recommended  by  Brand  of  Stettin,  is  applied  as  fol- 
lows : — A  sheet  is  quickly  wrung  out  of  ice-cold  water  and  wrapped 
several  times  round  the  patient's  body,  a  couple  of  dry  blankets  are 
then  applied  outside  the  wet  sheet,  and  a  Macintosh  outside  all. 
The  pack  is  very  refreshing  and  often  induces  sleep.  The 
Grafenberg  plan,  mentioned  with  approval  by  Hebra  and  Mayr  in 
their  account  of  the  treatment  of  scarlatina,  is  merely  a  variety  of 
this  "wet-pack,"  in  which  the  head  is  enveloped  in  wet  napkins, 
and  the  patient  is  given  cold  water  to  drink.  Ice,  also,  is  applied 
(Eisumschlage)  if  intense  congestion  is  present.  Dr.  Sydney  Ringer 
is  the  special  advocate  of  the  continuous  application  of  cloths 
wet  with  ice-cold  water  and  rung  nearly  dry.  They  should 
be  applied  one  below  the  other  from  the  chest  downwards.  This 
is  an  effectual  method  of  lowering  temperature. 

Immersion  in  cold  baths  is  the  method  now  most  in  fashion, 
particularly  on  the  Continent,  and  in  the  treatment  of  typhoid  fever. 
It  is  contra-indicated  in  haemorrhage  from  the  bowels.  When  the 
patient's  temperature  reaches  104°,  he  is  placed  in  a  bath  having  a 
temperature  of  from  50°  to  70°  F.,  or  better,  as  recommended  by 

a  Outlines  of  Medical  Treatment.  Third  Edition.  London  :  J.  and  A. 
Churchill.     1891.     Page  424. 


CURATIVE    TREATMENT.  55 

von  Ziemssen,  in  one  with  a  temperature  of  some  10°  below  that  of 
the  body,  but  which  after  the  patient's  immersion  is  gradually  cooled 
down  to  68°  by  adding  cold  water.  The  patient  should  remain  in 
the  bath  for  half  an  hour,  or  until  shivering  comes  on,  when  his 
limbs  should  be  rubbed  by  the  attendants,  he  should  be  quickly  dried 
and  put  into  a  warm  bed.  The  fullest  account  of  this  method  of 
treatment  will  be  found  in  Liebermeister's  article  on  "  Typhoid 
Fever"  in  the  first  volume  of  von  Ziemssen's  "  Cyclopajdia  of  the 
Practice  of  Medicine"  (page  208.) 

Dr.  Fenwicka  thus  describes  the  ''ice-cradle"  : — "I  was  led  to 
adopt  a  method  of  reducing  the  temperature  in  fever  which  I  have 
employed  for  many  years  at  the  London  Hospital  and  in  private 
practice,  and  which  seems  to  me  to  possess  the  advantages  of  the 
cold  bath  without  its  drawbacks.     It   is   generally  called  in  the 
hospital  the  '  ice-cradle,'  and  consists  of  an  ordinary  iron  surgical 
cradle,  of  sufficient  width  to  allow  the  patient  to  move  easily  beneath 
it,  and  long  enough  to  cover  the  whole  body.     In  it  are  suspended 
three  or  four  small  zinc  pails  filled  with  ice ;  the  bottoms  of  the 
pails  being  covered  with  a  piece  of  lint,  so  as  to  prevent  any  con- 
densed moisture  from  dripping  upon  the  patient's  body.     A  light 
coverlet  is  thrown  over  the  cradle,  an  aperture  being  left  at  either 
end,  in  order  to  allow  a  free  circulation  of  air  through  it.     Under 
this  the  patient  lies,  either  naked  or  covered  with  a  very  thin  opaque 
gauze,  whilst  a  hot  water-bottle  placed  against  the  feet  adds  to  his 
comfort,  and  assists  in  warding  off  any  tendency  to  chilliness.     If 
the  iron  framework  is  not  obtainable,  a  good  substitute  can  easily 
be  made  with  a  piece  of  stout  wire,  or  a  couple  of  wooden  hoops, 
such  as  children  are  accustomed  to  play  with  ;  a  string  or  wire  being 
fastened  along  the  centre,  from  which  the  pails  may  be  suspended." 
The  ice-cradle   has  been  used  for  many  years  at  the  London 
Hospital  with  satisfactory  results.     Many  severe  cases  of  typhoid 
fever  have  lain   beneath   it  for  a  fortnight,  or  even  longer— the 
temperature  remaining  constantly  below  104°.     Its   efficacy  was 
demonstrated  by  its  temporary  removal,  when  the  thermometer  in 
the  axilla  would  rise  to  105°  or  upwards.     It  is  not  applicable  in 
a  Loe.  cit.     Page  429. 


56  GENERAL    PRINCIPLES    OF    TREATMENT. 

cases  of  hyperpyrexia,  where  a  rapid  reduction  of  temperature  is 
indicated,  and  it  produces  at  first  a  certain  amount  of  discomfort. 
The  patieut,  however,  soon  becomes  accustomed  to  the  application 
of  the  cradle. 

In  1787,  cold  affusion  was  proposed  by  Dr.  Currie  of  Liverpool 
both  for  arresting  and  mitigating  continued  fevers.  The  patieut 
was  seated  naked  in  an  empty  tub  or  bath  and  several  buckets  of 
Water  of  a  temperature  of  40°  to  50°  F.  were  poured  from  a  height 
of  one  to  three  feet,  or  more,  over  the  head  and  chest.  He  was 
then  hastily  dried  and  placed  in  bed— the  operation  being  repeated 
once  or  twice  daily.  The  affusions  were  most  successful  when 
employed  at  the  beginning  of  the  fever,  but  even  later  this  treat- 
ment reduced  the  pulse  and  temperature,  relieved  many  of  the 
distressing  symptoms,  and  conducted  the  disease  to  a  safer  and 
speedier  issue.  Following  the  practice  of  Dr.  Stokes  at  the  Meath 
Hospital,8,  1  have  often  used  cold  affusion,  adopting  the  modified 
plan  of  pouring  cold  water  from  a  jug  over  the  head  and  face  of  a 
typhus-fever  patient  while  still  lying  in  bed  crossways,  his  head 
and  shoulders  being  supported  over  a  bath  placed  alongside  the 
bed.  The  stream  of  water  should  be  directed  upon  different  parts 
of  the  head  from  time  to  time,  for  otherwise  pain  may  be  caused. 
This  last  remark  bears  on  the  application  of  ice  to  the  head  also — 
a  procedure  of  which  Dr.  Stokes  speaks  in  terms  of  the  highest 
approbation.  He,  however,  observes  that  it  is  often  most  clumsily 
and  ineffectually  carried  out.  The  proper  method  is  to  place  a 
piece  of  ice,  rubbed  smooth  with  the  hand,  in  a  cup-shaped  sponge 
of  convenient  size.  Then,  by  inverting  the  sponge,  the  ice  may  be 
brought  into  contact  with  the  shaven  scalp  and  so  passed  round 
and  round  the  head  by  a  constant  gentle  motion.  The  sponge 
absorbs  the  water.  When  it  is  saturated  it  can  be  squeezed  out, 
the  ice  replaced  and  the  application  resumed.  In  this  way  no  pain 
is  caused,  the  proceeding  is  grateful  to  the  patient,  and  the  whole 
head  is  uniformly  and  gradually  cooled.b 

■ Lectures   on   Fever.     By    William    Stokes,    M.D.,    D.C.L.    Oxon.,   F.R.S. 
London  :  Longmans,  Green  &  Co.     1874.     Page  411. 
b  Loc.  cit.     Page  412. 


CURATIVE    TREATMENT.  57 

4.  While  we  endeavour  to  sustain  the  vital  powers  of  the  fever 
patient  by  appropriate  food  and  stimulants,  we  should  avoid  any- 
thing which  would  cause  congestion  or  put  an  additional  strain  on 
organs  already  overtasked  and  with  impaired  functions.  The  food 
should  he  both  nutritious  and  digestible,  consisting  of  such  articles 
as  milk,  eggs,  beeftea,  veal-broth,  chicken-broth,  mutton-broth 
(strained),  meat-essences,  meat-jellies,  arrowroot,  sago,  bread  and 
milk,  custard,  tea  or  coffee,  well  diluted  with  milk.  If  there  is  a 
tendency  to  diarrhoea,  the  milk  should  be  boiled,  or  lime  water 
should  be  given  with  it,  in  the  proportion  of  one  part  in  four  ;  or 
vermicelli,  gelatine  (isinglass),  or  arrowroot  should  be  added  to  the 
milk  or  broth.  Acids  should  not  be  given  with  milk,  which  they 
coagulate,  or  cause  to  curdle.  If  the  digestive  powers  are  very 
weak,  the  food  may  with  advantage  be  peptonized,  the  object  of 
which  process  is  to  convert  insoluble  proteids  or  albuminoids  into 
soluble  peptones. 

Food  should  be  given  to  the  fever  patient  at  regular  intervals — 
every  three  hours,  every  two  hours,  or  even  every  hour ;  but,  at 
the  same  time,  the  stomach  should  be  allowed  to  rest  for  at  least 
the  last-named  interval,  else  nausea,  vomiting,  flatulence,  and 
diarrhoea  may  be  caused  through  non-assimilation  and  decomposition 
of  the  food. 

When  a  patient  remains  in  a  state  of  stupor  he  should  be  roused 
from  time  to  time  to  take  food  ;  but,  if  he  falls  into  a  tranquil 
sleep  after  a  period  of  wakefulness,  nervous  excitement,  or  delirium, 
he  should  not  be  aroused  merely  because  the  hour  for  food  has  come 
round.  In  delirious  cases,  or  when  the  patient  is  unconscious,  or 
unable  to  swallow,  liquid  nourishment  should  be  introduced  into 
the  stomach  by  a  long  tube  passed  through  the  nares,  or  nutrient 
enemata  should  be  administered.  In  the  latter  case  the  rectum 
should  first  be  washed  out  by  a  lavement  of  warm  water,  and  then 
an  enema  should  be  given  of  milk  and  brandy,  or  beef-tea,  or  egg- 
flip,  at  a  suitable  temperature  (100°  F.),  and  of  moderate  size  (not 
exceeding  4  to  6  oz.). 

It  used  to  be  the  practice  to  half-starve  the  unhappy  and  ill- 
starred  fever-patient;  but    Dr.    Graves    changed   all    that.      Dr. 


«-'o  GENERAL    PRINCIPLES   OF   TREATMENT. 

Stokes  a  narrates  how  his  distinguished  colleague  was  going  round 
the  Meath  Hospital,  when  he  began  to  expatiate  on  the  healthy 
appearance  of  some  convalescents  from  typhus.  "This  is  all  the 
effect  of  our  good  feeding,"  he  exclaimed,  "  and  lest,  when  I  am 
gone,  you  may  be  at  a  loss  for  an  epitaph  for  me,  let  me  give  you 
one  in  three  words,  '  He  fed  fevers.' "  This  is  all  very  well,  but 
there  is  reason  to  fear  that  the  pendulum  has  swung  rather  too 
much  in  the  other  direction  of  late  years,  and  that  fever  patients 
have  been  overfed,  rather  than  underfed.  Very  few  patients  can 
digest  more  than  one  pint  of  animal  broth,  and  from  one  and  a  half 
to  two  pints  of  milk,  in  the  twenty-four  hours,  and  these  quantities 
seem  to  be  a  fair  allowance,  under  all  the  circumstances,  in  the  case 
of  an  adult. 

The  question  of  the  administration  of  alcoholic  stimulants  in 
fever  is  an  anxious  one.  Here,  also,  medical  practice  has  been 
pushed  to  opposite  extremes  at  different  times.  At  present  there 
is  a  distinct  reaction  from  the  liberal  use  of  stimulants  advocated 
and  employed  by  Alison,  Graves,  Todd,  and  Stokes  ;  and  the  result 
has,  in  my  opinion,  been  satisfactory,  although  we  seem  to  be  in 
some  danger  of  running  into  the  other  extreme  of  withholding 
wine  or  spirit  when  its  use  would  really  benefit  the  patient. 
Murchisonb  lays  down  excellent  rules  for  our  guidance  in  the 
use  of  stimulants.  He  considers  that  patients  under  twenty  years 
of  age  do  best  as  a  rule  without  any  alcohol,  whereas  most  patients 
over  forty  are  benefited  by  it  after  the  first  week  of  the  fever. 
Intemperate  persons  require  alcohol  earlier  and  in  greater  quantity 
than  others,  and  yet  it  does  not  always  agree.  The  chief  indica- 
tions for  the  use  of  stimulants  are  derived  from  the  state  of  the 
pulse,  the  heart,  the  tongue,  and  the  brain,  and  from  the  presence 
of  complications,  and  especially  of  the  "  typhoid  state "  {i.e., 
stupor,  low  muttering  delirium,  tremor,  subsultus,  involuntary 
evacuations,  coma  vigil,  &c). 

a  Studies  in  Physiology  and  Medicine.     By  the  late  Robert  James  Graves, 
F.R.S.     Edited  by  William  Stokes,  Regius  Professor  of  Physic  in  the  Univer- 
sity of  Dublin.     London  :  John  Churchill  &  Sous.     1863.     Page  lix.  of  the 
"  Biographical  Notice  "  by  Dr.  Stokes. 
.    b  Loo.  cit.     Pagts  291  and  292. 


CURATIVE    TREATMENT.  59 

Alcoholic  stimulants  are  doing  a  fever  patient  good  if,  under 
their  use — 

1.  The  heart's  action  becomes  stronger  and  less  rapid,  the  im- 

pulse increasing  in  strength  and  the  first  sound  becoming 
more  distinct. 

2.  A  soft,  compressible,  undulating,  irregular,  or    intermitting 
'        pulse  becomes  fuller  and  stronger,  and   more   regular   in 

rhythm  and  volume. 

3.  A  dry,  brown  tongue  becomes  clean  and  moist  at  the  edges. 

4.  Delirium  lessens,  the    patient    becoming    more    tranquil,  or 

even  falling  asleep. 

Stimulants  are  most  urgently  required  during  the  night  and  in 
the  early  morning,  when  the  vital  powers  are  wont  to  flag.  In  the 
forenoon  they  are  less  necessary. 

In  cases  of  extreme  prostration,  medicinal  stimulants  or  tonics 
should  be  combined  with  wine  or  spirits.  The  preparations  and 
drugs  mostly  employed  under  these  circumstances  are  —  carbonate 
of  ammonium,  the  different  ethers,  camphor,  musk,  turpentine, 
bark,  or  quinine. 

In  addition  to  all  these  measures,  the  fever  patient  should  husband 
his  strength  by  taking  to  bed  at  the  earliest  opportunity  and  re- 
maining there  until  convalescence  has  begun — in  a  word,  the 
patient  must  be  prevented  in  every  way  from  exhausting  his  mus- 
cular and  nervous  powers. 

5.  Until  its  own  specific  remedy  is  discovered  in  the  case  of 
each  of  the  infective  febrile  disorders,  one  of  the  main  objects  of 
treatment  must  be  the  relief  of  distressing  symptoms — the  treat- 
ment must  be  largely  symptomatic. 

Of  these  symptoms  headache  is  one  of  the  most  common  and 
earliest  to  appear.  It  is  sometimes  relieved  by  an  emetic  of 
ipecacuanha  (20  grains)  and  antimony  (1  grain),  or  of  carbonate 
of  ammonium  (40  grains)  (Murchison),  or  by.  an  action  of  the 
bowels,  or  by  the  application  of  evaporating  lotions  or  of  warm 
fomentations  to  the  forehead.  Failing  these  measures,  the  hair 
should  be  cut  close  or  the  head  shaved,  and  cold  affusion  tried,  or 


60  GENERAL   PRINCIPLES   OF   TREATMENT. 

ice  applied  as  described  above.  A  blister  or  sinapism  applied  to 
the  forehead  or  nape  often  does  good;  or,  in  the  case  of  a  young 
and  robust  patient,  leeching  the  temples  or  mastoid  process  is  very 
efficacious.  A  curious  and  beneficial  effect  of  local  depletion  will 
be  noticed  in  our  account  of  smallpox. 

Sleeplessness,  nervous  excitement,  and  delirium  may  often  be 
controlled  by  the  measures  recommended  for  the  relief  of  headache. 
Good  nursing  tells  against  these  most  exhausting  symptoms.  The 
proper  alternation  of  day  and  night  conduces  to  sleep,  so  the  room 
should  not  be  darkened  in  the  daytime,  unless  photophobia  is 
present.  Whispering  in  the  sick-room  should  be  forbidden — far 
better  to  talk  aloud,  if  it  is  necessary  to  talk  at  all.  In  private 
practice  the  plan  of  having  two  beds,  and  changing  the  patient 
from  one  to  the  other  every  twelve  hours  or  so,  often  brings  on  sleep. 
Should  all  these  measures  fail,  and  if  the  patient  has  had  little  or 
no  sleep  for  thirty-six  hours,  recourse  must  be  had  to  hypnotics. 
It  would  be  outside  the  scope  of  a  Text-book  to  do  more  than  direct 
attention  to  a  very  few  selected  drugs  and  formula?.  Foremost 
among  hypnotics  stands  opium,  which,  unfortunately,  has  the  dis- 
advantage of  tending  to  lock  up  the  secretions.  Nevertheless,  to 
an  adult,  whose  kidneys  are  sound,  15  to  20  minims  of  Battley's 
solution  may  be  given  ;  or  20  to  30  minims  of  the  solutions  of  the 
hydrochlorate  or  acetate  or  bimeconate  of  morphin,  or  5  grains  of 
the  compound  soap-pill  of  the  pharmacopoeia,  or  10  grains  of  the 
compound  powder  of  ipecacuanha,  or  better  still,  a  pill  representing 
that  dose  and  consisting  of  1  grain  each  of  extract  of  opium  and  of 
ipecacuanha,  with  2  grains  of  extract  of  hyoscyamus.  A  hypodermic 
injection  of  morphin  (|—  £  grain)  may  be  substituted  for  any  of  the 
foregoing,  if  preferred.  Graves  used  to  combine  tartar  emetic  with 
opium,  and  with  excellent  effect  in  the  persistent  insomnia  of 
typhus  with  delirium.  His  formula  was  a  mixture  containing  4 
grains  of  tartar  emetic  and  one  drachm  of  laudanum  in  eight  ounces 
of  camphor  water  a — of  this  the  dose  usually  given  was  two  to  four 

a  Clinical  Lectures  on  the  Practice  of  Medicine.  By  Robert  James  Graves, 
M.D.,  F.R.S.  Edited  by  John  Moore  Neligan,  M.D.  Dublin  :  Fannin  &  Co! 
186L     Page  177. 


CURATIVE    TREATMENT.  6  L 

drachms  every  second  hour  until  the  patient  slept.  He  varied  the 
relative  proportions  of  tartar  emetic  and  laudanum  in  the  mixture 
according  to  circumstances,  and  laid  down  as  a  rule  that  "  the  prac- 
titioner must  in  all  cases  watch  the  effects  of  this  medicine  from  hour  to 
hour  until  he  ascertain  whether  it  agrees  with  the  patient  or  not." 
The  italics  are  in  the  original. 

Murchison  proposed  that  digitalis  should  be  given  in  combina- 
tion with  the  opium  or  morphin,  and  there  is  no  doubt  that  by 
these  combinations  sleep  will  be  induced  in  many  cases  where 
opium  alone  would  fail  or  be  contra-indicated.  Murchison's  pre- 
scription is  as  follows  : — 

fy.  Liquor  Opii  Sedativi,  3.)  ; 
Tincturse  Digitalis,  3j  ; 
Spt.  iEtheris  Nitrosi,  3ij  ; 
Aquae  Camphorae,  ad  §vj  ; 
M.  Sumat  coch.  mag.  ij  statim,  et  coch.  mag.  j  secunda  quaque 
bora  usque  ad  somnum.     (One  fluid  ounce  at  once,  and  half  a  fluid 
ounce  every  second  hour  until  the  patient  sleeps.) 

It  should  not  be  forgotten  that  opium  in  any  form  is  contra- 
indicated: — (a),  in  infants  ;  (b),  when  there  is  evidence  of  extensive 
pulmonary  engorgement ;  (c),  when  the  pupil  is  persistently  con- 
tracted ;  (d),  when  the  urine  is  scanty,  bloody,  or  highly  albuminous  ; 
and  (e),  when  the  patient,  although  sleepless,  is  in  a  state  of  pro- 
found nervous  prostration  (the  ataxic  or  typhoid  condition)  and  quite 
unconscious. 

Murchison  also  recommends  20  grains  of  chloral  with  a  drachm 
of  syrup  of  orange-peel  and  seven  drachms  of  peppermint  water  as 
a  hypnotic  for  an  adult  fever  patient,  and  I  have  found  chloral 
very  useful  even  in  young  children,  given  in  this  form — 
$.  Syrup.  Chloral  (B.  P.),  3j  ; 
Syrup.  Simplicis,  3vij. 
M.  ft.  mist.  Signa :  "  A  teaspoonful  every  hour  until  sleep  sets  in." 

At  the  same  time,  and  notwithstanding  the  prestige  of  Murchison's 
name,  I  have  come  to  the  conclusion  that  chloral  is  not  a  safe 
hypnotic  in  fever,  and  it  must  always  be  given  most  cautiously  in 
typhus,  or  where  there  are   any  signs   of   failing  heart.     Other 


62  GENERAL   PRINCIPLES    OF   TREATMENT. 

sedatives  sometimes  employed  are  the  bromides  of  sodium,  potassium, 
and  ammonium ;  belladonna,  henbane,  Indian  hemp,  chloroform, 
camphor  and  musk  (the  last  especially  in  the  ataxic  state).  A 
prescription  of  Graves  may  be  quoted — it  was  a  draught,  to  be 
taken  every  two  hours,  containing  half  a  grain  of  tartarated 
antimony  (tartar  emetic),  ten  grains  of  musk,  five  grains  of 
camphor,  and  tend  rops  of  laudanum.  After  taking  three  such 
doses  the  patient  fell  into  a  quiet  sleep,  and  awoke  quite  rational.* 
Dr.  Daniel  Lysons,  of  Bath,  in  the  year  1771,  prescribed  the 
following  camphor  draught  in  fever  with  good  effect : — 
R,.   Camphorae,  gr.  20  ; 

Spt.  Rectificati,  min.  vj  ; 

Pulv.  Gummi  Acaciae,  gr.  20  ; 

Potassii  Nitratis,  gr.  10  ; 

Sacchari  Albi,  gr.  60  ; 

Aquae,  §ij. 
M.  ft.  haustus. 
When  prescribing  the  bromides,  it  is  well  to  order  them  to  be 
freely  diluted.     They  may  be  given  in  full  doses,  even  up  to  60 
grains,  at  least  two  hours  before  sleep  is  expected. 

In  cases  of  profound  stupor,  attention  should  be  directed  to  the 
state  of  the  bladder.  Timely  use  of  the  catheter  may  at  once  relieve 
retention  of  urine  and  cerebral  oppression,  and  obviate  a  troublesome 
cystitis.  An  attempt  should  be  made  to  rouse  the  patient  by  external 
stimulating  applications — rapid  blistering  of  the  shaven  scalp  or  fore- 
head by  painting  with  liquor  epispasticus  or  acetum  cantharidis,  or  by 
applying  lint  saturated  with  strong  solution  of  ammonia  under  oiled 
silk  for  five  or  six  minutes ;  the  application  of  sinapisms  to  the 
inside  of  the  thighs,  the  soles  of  the  feet,  the  epigastrium,  or  the 
nape  of  the  neck — are  all  efficient  means.  Personally,  I  have  the 
greatest  faith  in  wrapping  the  lower  extremities  and  waist  in 
flannels  wrung  out  of  mustard  and  hot  water.  The  cold  effusion 
or  douche,  as  already  described,  is  highly  recommended  by  Dr. 
Armitage  and  Dr.  Todd.     Among  drugs,  valerian  and  phosphorus 

a  Graves.     Loc.  cit.    Page  140. 


CURATIVE    TREATMENT.  63 

have  been  highly  spoken  of  for  tlie  coma  of  typhus,  but  Murchison 
"damns  them  with  faint  praise."  Phosphorus,  in  particular,  is 
lauded  by  Huss  (1855)  as  a  remedy  in  cases  of  extreme  torpor  and 
prostration.  It  may  be  given  dissolved  in  almond  oil  in  doses  of 
one-twelfth  of  a  grain  every  second  or  third  hour. 

Convulsions  are  often  transitory  at  the  beginning  of  a  specific 
fever,  but  they  constitute  a  very  dangerous  and  intractable  symptom 
in  the  later  stages,  when  they  are  often  of  uraemic  origin  or  usher 
in  some  complication.  The  bowels  should  be  freely  moved  by  a 
dose  of  calomel  or  croton  oil  (except  in  typhoid  fever),  the  patient 
should  be  aroused  from  stupor  as  above  recommended,  the  state  of 
the  bladder  should  be  attended  to,  and  congestion  of  the  kidneys 
should  be  relieved  by  dry  cupping  and  poulticing,  the  hot-air  bath, 
or  the  hot-pack,  while  their  action  is  promoted  by  copious  draughts 
of  water,  saline  diuretics,  and  digitalis. 

Hypersesthesia  may  be  relieved  by  warm  fomentations,  or  dry 
rubbing  (shampooing),  or  by  hypnotics  and  anodynes. 

Rheumatoid  and  neuralgic  pains  may  be  treated  in  the  same 
way  as  hyperesthesia,  or  a  few  moderate  (5-grain)  doses  of  phena- 
zone  or  of  quinine  may  be  given. 

Thirst  is  best  assuaged  by  draughts  of  cold  water,  if  need  be 
slightly  acidulated  or  embittered  with  cascarilla  or  quassia  (Mur- 
chison). According  to  the  late  Dr.  R.  D.  Lyons,  of  Dublin, 
camphor  is  often  a  specific  against  thirst.  It  may  be  given  in  the 
form  of  camphor  water. 

Persistent  vomiting  is  best  treated  by  applying  a  sinapism  to 
the  pit  of  the  stomach  or  nape  of  the  neck,  the  administration  of 
ice,  lime-water,  Schacht's  solution  of  bismuth,  magnesium,  or 
effervescing  draughts  with  dilute  hydrocyanic  acid.  The  bowels 
should  be  kept  free. 

Tympanites  or  meteorism  (flatulent  distension  of  the  abdomen 
from  inflation  of  the  intestines  with  gas)  and  hiccough  may  be 
treated  with  antispasmodics  internally — such  as  30-minim  doses  of 
aromatic  spirit  of  ammonium  or  of  compound  spirit  of  horse-radish, 
turpentine,  peppermint  with  carbolic  acid,  &c. ;  or  with  enemata 
of  turpentine,  asafcetida,  and  rue  ;  of  creasote  or  carbolic  acid.    The 


64  GENERAL  PRINCIPLES    OF    TREATMENT. 

best  external  applications  are  hot  fomentations, poultices,  turpentine- 
epithems,  and  above  all,  ice-poultices,  as  recommended  by  Dr. 
Peter,  of  Paris.  Dr.  Cayley  says  the  ice-poultice  may  be  con- 
veniently applied  by  putting  small  pieces  of  ice  between  two  folds 
of  flannel.  This  is  especially  useful  in  intestinal  hasmorrhage  in 
typhoid  fever.  Failing  all  these  means,  the  long  tube  should  be 
passed  as  far  up  the  intestine  as  possible,  and  the  colon  even  lias 
been  punctured  to  give  vent  to  the  pent-up  gas. 

The  treatment  of  diarrhoea  and  of  intestinal  haemorrhage  will 
require  special  mention  when  we  come  to  the  subject  of  typhoid 
fever,  in  which  disease  they  most  frequently  present  themselves. 

6.  In  the  management  of  the  various  complications  and  sequela? 
of  the  different  infective  febrile  diseases  "  we  must  "  (as  Murchison 
says,  when  speaking  of  Typhus),  "  be  guided  by  general  principles 
and  by  the  symptoms  in  the  individual  case,  never  forgetting  that 
the  primary  disease  "  (and  this  is  true  in  varying  degrees  of  all  tlie 
diseases  we  are  considering)  "  has  a  tendency  to  induce  great  nervous 
prostration  and  depression  of  the  heart's  action,  which  forbid  all 
depleting  or  lowering  measures."8. 

The  subject  of  the  treatment  of  complications  and  sequelae  will 
be  more  conveniently  discussed  under  the  headings  of  the  respec- 
tive infective  fevers. 

a  Loc.  cit.     306. 


PAKT  II. 


THE     EXANTHEMATA,     OR 
ERUPTIVE     FEVERS. 


PART  II.— THE  EXANTHEMATA,  OR 
ERUPTIVE  FEVERS. 


CHAPTER  VI. 

General  Considerations. 


Cullen's  classification  of  Diseases. — Four  Orders  of  Pyrexiae. — Definition  of 
the  Exanthemata. — Meaning  of  the  terra  4^dv8r)fj.a. — Enumeration  of  the 
common  acute  Micro-parasitic. Diseases  which  are  called  "Eruptive  Fevers." — 
Smallpox,  the  "  paradigm  "  or  type. 

So  far  as  I  can  ascertain,  the  expression  "  Exanthemata,  or 
Eruptive  Fevers"  was  first  introduced  by  Dr.  William  Cullen, 
Professor  of  the  Practice  of  Physic  in  the  University  of  Edinburgh, 
in  his  "Synopsis  Nosologic  Methodicae,"  published  in  1784.  a  He 
divided  all  diseases  into  four  classes — Pyrexia,  Neuroses,  Cachexia, 
and  Locales.  His  definition  of  the  first  is  excellent,  as  far  as  it 
goes  —  "Post  horrorem  pulsus  frequens,  calor  major,  plures  func- 
tiones  lsesae,  viribus  praesertim  artuum  imminutis."  ("  After  a 
shivering  fit,  a  rapid  pulse,  increased  body  heat,  impairment  of 
many  functions,  diminished  strength,  especially  of  the  limbs.") 
He  arranged  the  Pyrexiae  in  four  orders— 1.  Febres,  including  the 
Intermittent  and  the  Continued  Fevers.  2.  Phlegmasia,  or  Inflam- 
mations. 3.  Exanthemata,  or  Eruptive  Fevers.  And  4.  Hoemor- 
rhagia,  or  Bleedings  and  Catarrhal  Fluxes. 

Cullen's  definition  of  the  Exanthemata  is  well  worth  quoting. 
It  runs  as  follows : — "  Morbi  contagiosi,  semel  tantum  in  decursu 
vitse  aliquem  afficientes ;  cum  febre  incipientes ;  definite-  tem- 
pore apparent  phlogoses,  ssepe  plures,  exiguae  per  cutem 
sparsse."  This  may  be  translated  freely  :  "  Infectious,  or  taking, 
diseases  attacking  an  individual  (as  a  rule)  once  only  in  the  course 

a  See  The  Works  of  William  Cullen,  M.J).  Edited  by  John  Thomson,  M.D., 
F.R.S.,  L.  &  E.  In  two  volumes.  William  Blackwood,  Edinburgh.  1827. 
Vol.  I.,  pages  243  and  276. 


68  GENERAL   CONSIDERATIONS. 

of  his  life,  setting  in  with  fever,  and  characterised  by  the  appear- 
ance at  a  definite  time  of  an  inflammatory  red  rash,  consisting  of 
papules,  often  many  in  number,  of  small  size,  scattered  over  the 
skin." 

It  will  be  observed  that  Cullen  was  careful  not  to  include  typhus 
and  typhoid  fevers,  which  he  called  respectively  "  Typhus  petechi- 
alis  "  and  "  Typhus  mitior,"  or  "  Synochus  "  pro  parte  (Murchison), 
among  the  Exanthemata.  It  is  true  that  some  modern  writers  do 
not  follow  his  example  in  this  matter.  For  example,  Dr.  William 
Squire,  in  an  otherwise  excellent  article  on  the  "  Exanthemata,"  in 
Quain's  "  Dictionary  of  Medicine,"  includes  both  these  fevers 
among  the  true  exanthemata,  which  he  rightly  says  "  are  acute 
specific  infectious  diseases." 

In  the  present  work  I  intend  to  follow  Cullen's  example,  which 
has  been  endorsed  by  such  high  authorities  as  Murchison,  Striimpell, 
and,  apparently,  Trousseau. 

It  is  indeed  true  that  I  look  upon  the  rose  spots  of  typhoid  and 
the  maculae  of  typhus  as  true  rashes,  but  their  appearance  is  com- 
paratively inconstant.  The  classification  of  these  fevers  with  the 
Exanthemata  would  further  have  the  awkward  result  of  leaving 
Eelapsing  Fever  in  a  class  by  itself,  unaccompanied,  as  it  is,  by 
any  rash  yet  running  a  definite  course  like  typhus  and  typhoid, 
and  certainly  due,  like  them,  to  a  specific  cause. 

The  Greek  term  i^avOrj^a,  which  means  an  efflorescence,  or  an 
eruption  or  rash,  was  used  by  Hippocrates  in  this  sense.  It  is, 
therefore,  classical.  It  is  derived  from  the  verb  e^avOew,  to  put 
out  flowers  (av6os,  a  blossom,  a  flower). 

The  common  acute  micro-parasitic  diseases,  or  infective  fevers, 
which  are  characterised  by  the  appearance  at  a  definite  period 
in  their  course  of  a  rash  upon  the  skin,  are — (1)  Smallpox, 
(2)  Chickenpox,  (3)  Measles,  (4)  Scarlet  Fever,  (5)  Epidemic 
Rose-rash,  (6)  Erysipelas.  Of  the  entire  group  Smallpox  is  always 
taken  as  the  paradigm,a  or  pattern,  and  we  will  accordingly  begin 
with  a  description  of  this  terrible  disease. 

aGk.  irapaSeiy/jLa,  a  pattern,  model,  example.    Latin  :  Exemplar. 


69 


CHAPTER  VII. 

Variola,  or  Smallpox. 

Nomenclature. — Definition. — ^Etiology  (historical  sketch). — Exciting  cause  : 
contagion. — Predisposing  causes  :  susceptibility,  from  non-protection,  season, 
race. — Bacteriology  of  Smallpox. — Modes  of  dispersion  of  the  morbid  poison. — 
"  Striking  Distance"  of  the  disease. — Chief  Stages  of  Infectiveness. — Clinical 
History  :  Incubation,  Invasion,  Eruption  (its  five  stages  of  development  : 
Specks  of  Hypersemia,  Papules  or  Pimples,  Vesicles,  Pustules,  Scabs  or  Crusts), 
Desiccation,  Desquamation. — Variolous  Exanthem  upon  the  Mucous  Mem- 
branes, but  not  upon  the  Serous  Membranes. 

Nomenclature — Smallpox. — Synon. : — Variola  (from  Lat.  Varus, 
a  blotch,  a  pimple) ;  Germ.  Blattern,  Pocken  ;  Fr.  Petite  VeVole, 
Picote,3,  Variole ;  ltal.  Vaiuolo ;  Span.  Viruelas ;  Danish  and 
Norwegian,  Kopper  ;  Swedish,  Smittkoppor. 

"  Pox  "  is  one  of  the  plural  forms  of  "  Pock,"  derived  from  the 
Anglo-Saxon  poc  or  pocc,  a  bag  or  pouch.     Chaucer  has  this  line — 

"Of  pokkes  and  of  scab  and  every  sore." 

The  English  term  Smallpox  was  introduced  at  the  end  of  the 
15th  century  to  distinguish  the  disease  from  Syphilis.  Varioloid 
is  modified  Smallpox — the  result  of  (a)  a  previous  attack,  (b)  inocula- 
tion, (c)  vaccination.  In  this  variety  of  the  disorder  the  febrile  move- 
ment is  usually  moderate,  and  there  is  little  or  no  secondary  fever- 

Definition. — An  acute  specific,  infectious  febrile  disorder,  setting 
in  suddenly  with  chills,  headache,  sweating,  vomiting,  tenderness 
on  pressure  in  the  epigastrium,15  and  severe  pain  in  the  lumbar 
region ;  characterised  by  a  certain  typical  range  of  temperature,  a 
specific  inflammation  of  the  skin  (dermatitis)  and  often  of  the 
mucous  membranes  also.  The  dermatitis  is  shown  by  the  develop- 
ment, usually  on  the  third  day,  of  a  papular  or  pimply  rash,  which 
quickly  becomes  vesicular  and  finally  pustular ;  the  appearance  of 
the  rash  is  followed  by  a  fall  of  temperature,  but  a  secondary  fever 

a  A  man  marked  with  Smallpox  is  said  to  be  picote. 

b  "  A  Pain  at  the  Cavitv  of  the  Breast  beneath  the  Region  of  the  Heart." 
(Sydenham).  .  .  , 


70  SMALLPOX. 

accompanies  the  development  of  pustules  at  the  end  of  the  first 
week.  These  pustules  finally  dry  up  (desiccation)  and  form  crusts, 
which  are  shed  or  cast  off  about  the  eighteenth  day.  The  disease 
is  not  infrequently  complicated  with  haemorrhages  into  the  skin 
(Purpuric  Smallpox)  and  from  the  mucous  membranes  (Hemorrhagic 
Smallpox). 

iEtiology. — The  origin  of  Smallpox  is  unknown.  It  was  first 
described  by  the  Arabian  physician,  Rhazes,  who  flourished  in  the 
tenth  century.  Rhazes  speaks  of  the  Smallpox  as  a  disease 
generally  known  over  the  East,  but  the  occurrence  of  the  malady 
on  European  soil  cannot  be  traced  back  with  certainty  beyond  the 
Christian  era.  The  native  foci  of  smallpox  may  be  looked  for  in 
India  and  in  the  countries  of  Central  Africa ;  from  these  original 
habitats  its  diffusion  over  the  earth's  surface  has  been  brought 
about  by  successive  importations  of  the  morbid  poison.  At  the 
present  time  the  dominion  of  smallpox  extends  over  almost  the 
whole  inhabited  globe,  and  only  a  few  isolated  regions  still  enjoy  a 
complete  immunity  from  it.a  It  is  generally  believed  that  the 
disease  first  appeared  at  Pelusium,  in  Egypt,  A.D.  544  (Procopius  : 
de  Bello  Persico,  Lib.  II.  cap.  22).  Its  diffusion,  eastward  and 
westward,  was  probably  effected  by  the  Saracen  armies,  led  forth 
to  conquest  by  Mahomet  at  the  era  of  the  Hegira,  A.D.  622.  The 
name  "  Variola  "  occurs  for  the  first  time  as  a  designation  of  the 
disease  in  a  description  by  Marius,  of  Avenches,  of  an  epidemic 
which  was  widely  prevalent  in  France  and  Italy  in  the  year  570.b 

The  researches  of  antiquarians  lead  to  the  belief  that  smallpox 
first  appeared  in  England  about  the  year  900.  All  authors  concur 
in  representing  the  dreadful  mortality  occasioned  by  this  pestilence 
and  the  consequent  terror  which  its  visitations  everywhere  excited.e 
To  Boerhaave,  of  Leyden.  belongs  the  credit  of  assigning  contagion 
as  the  proper  exciting  cause  of  the  disease. 

a  Cf.  Handbook  of  Geographical  and  Historical  Pathology.  By  Dr.  August 
Hirsch,  New  Sydenham  Society,     1883.     Vol.  I.,  123,  et  seq. 

b  "  Chronicon  "  in  Bouquet's  Collections  des  Historiens  de  France.  Paris. 
1738.     Vol.  II.,  page  18.     [Quoted  by  Hirsch,  loc.  cit.  p.  126]. 

c  Elements  of  the  Theory  and  Practice  of  Medicine.  By  George  Gregory, 
M.D.     Fourth  Edition.     London:  Baldwin  and  Cradock.     1835.     Page  105. 


X 

o 

a. 


52 

CD-     " 
< 


SMALLPOX.  71 

Hirsch  is  of  opinion  that  there  are  two  factors  only  which  deter- 
mine the  recurrence  of  an  epidemic  of  smallpox — on  the  one  hand, 
the  necessary  number  of  persons  susceptible  of  the  morbid  poison, 
and,  on  the  other  hand,  the  introduction  of  the  virus  itself.  The 
disease  shows  a  singular  independence  of  climate  and  soil,  thriving 
equally  well  wherever  its  contagium  is  carried,  and  wherever  it 
finds  a  population  open  to  its  reception — being  unprotected  by  a 
previous  visitation,  or  inoculation,  or  vaccination.  It  is  this  latter 
circumstance  which  explains  the  periodicity  of  epidemics  of  small- 
pox in  various  districts  or  places. 

Although  the  occurrence  of  smallpox  is  apparently  independent 
of  climate,  yet  the  season  of  the  year  has  a  marked  influence  upon 
the  prevalence  of  the  disease.  Nearly  all  writers  are  agreed  that, 
while  outbreaks  of  smallpox  may  occur  at  all  seasons,  they  mostly 
begin  towards  the  end  of  autumn  and  in  the  early  spring,  or  in  the 
cold  season.  In  a  word,  smallpox  is  essentially  a  disease  of 
winter  and  spring.  In  the  British  Islands,  and  Western  Europe 
generally,  for  example,  the  monthly  number  of  cases  is  high  from 
November  onwards  ;  but  from  May  a  rapid  decline  in  the  preva- 
lence of  the  disease  takes  place,  the  least  number  of  cases  being 
observed  in  September. 

The  accompanying  Diagram  (1)  is  copied  from  the  Annual  Sum- 
mary of  Births  and  Deaths  of  the  Registrar-General  for  England 
for  1890.  It  shows  the  weekly  departure  from  the  average  weekly 
number  of  deaths  from  smallpox  (17)  in  London  in  the  fifty  years, 
1841-1890,  inclusive. 

In  this  diagram  the  thick  horizontal  line  represents  the  mean 
weekly  mortality  from  smallpox  in  London,  on  the  supposition  that 
the  mortality  is  spread  equally  over  the  52  weeks  of  the  year — the 
53rd  week,  when  it  occurs,  being  ignored.  The  curved  line  repre- 
sents the  amount  per  cent,  by  which  the  average  mortality  in  each 
week  differs  from  this  mean.  When  the  percentage  for  any  week 
is  above  the  mean,  the  amount  of  the  percentage  excess  is  marked 
above  the  horizontal  line  representing  the  mean ;  and  when  the 
percentage  is  below  the  mean  it  is  marked  below  the  line. 

It  must  be  remembered  that  the  data  on  which  the  curve  is 


72  SMALLPOX. 

formed  are  the  deaths  registered  in  each  week,  not  the  deaths  which 
occurred  in  the  week,  and  that  the  registration  is  usually  a  few  days 
after  the  death ;  and,  secondly,  that  the  curve  relates  to  deaths — 
that  is,  the  final  termination  of  the  attack  of  illness,  and  not  its 
commencement.  So  that,  in  estimating  the  effect  of  season  in 
generating  smallpox,  allowance  must  be  made  for  the  average 
duration  of  this  disease  when  fatal — that  is,  11  or  12  days.  It  is, 
moreover,  possible  that  the  curve  of  mortality  may,  for  another 
reason,  not  accurately  represent  the  curve  of  prevalence.  For  it 
may  be  that  an  attack  of  smallpox  is  more  likely  to  terminate 
fatally  if  it  occurs  at  one  season — for  example,  midwinter — than 
if  it  occurs  at  another,  such  as  midsummer. 

The  diagram  shows  that  at  ttte  beginning  of  February  and  in 
the  second  half  of  May  the  weekly  number  of  deaths  was  35  per 
cent,  in  excess  of  the  average  weekly  number  of  17  deaths  repre- 
sented by  the  mean  line,  whereas  at  the  end  of  September  there  was 
a  deficit  of  43  per  cent,  in  the  weekly  number  of  deaths  as  com- 
pared with  the  same  average  weekly  number  over  the  whole 
year. 

In  Dublin,  during  the  autumn  of  1871,  the  prevalence  of,  and  mor- 
tality from  smallpox  increased  with  a  fall  of  mean  temperature 
below  50°,  and  the  greatest  severity  of  the  epidemic  was  expe- 
rienced in  the  first  half  of  the  following  April,  shortly  after  a  period 
of  intense  cold  for  the  time  of  year.  With  the  rise  of  mean  temper- 
ature to  between  55°  and  60°  in  the  middle  of  June,  1872,  the 
epidemic  declined  rapidly.  Abundant  rainfalls  seemed  to  be  fol- 
lowed by  remissions  in  the  severity  of  the  epidemic,  and  the  con- 
verse was  also  true.a 

Individual  susceptibility  to  the  poison  of  smallpox  extends  to 
the  whole  of  mankind,  but  experience  shows  that  the  coloured 
races,  and  particularly  the  negro  race,  are — other  things  being 
equal — in  greater  risk  from  smallpox  than  the  whites.b 

a  Manual  of  Public  Health  for  Ireland.  Dublin :  Fannin  &  Co.,  1875.  Page 
298.  See  also  Buchan's  and  Mitchell's  Paper  in  the  Journal  of  the  Scottish 
M eteorologial  Society.     1874. 

b  Primer.  Die  Krankheiten  des  Orients.  ErlaDgan.  1847.  Page  120. 
[Qui ted  by  Hirscb,  loc.  cit.     Page  151.] 


SMALLPOX.  73 

The  bacteriology  of  Smallpox  is  still  incomplete.  According  to 
Edgar  M.  Crookshank,a  cocci,  '5  Ph  in  diameter,  singly,  in  pairs, 
and  in  long  or  short  chains,  and  colonies  have  been  found  by  Cohn 
(Virchow's  Archiv,  1872)  in  the  fresh  lymph  of  human  and  cowpox, 
and  in  the  pustules  of  true  smallpox.  They  are  regarded  as  the 
active  principle  of  vaccine  lymph,  since  filtration  deprives  this  of  its 
infectious  element  (Chauveau.  Comptes  liendus,  1868).  Burdon 
Sanderson  confirmed  this  observation.  The  lymphatics  of  the  skin 
in  the  region  of  the  pustule  of  both  human  and  sheep-pox  (Variola 
ovina)  are  filled  with  cocci  (Weigert  and  Klein).  Successful 
vaccination  has  been  stated  by  Quist  (St.  Petersburg  med.  Wochen- 
schrift,  1883)  to  result  from  artificial  cultivations.  These  cocci 
have  been  called  Streptococcus0  vaiiolce  et  vaccinias.  Loeff  and  Pfeiffer 
(Centralbl.  fur  Bacteriologie  und  Parasitenkunde,  1887)  have 
discovered  in  the  blood  of  smallpox  patients  certain  protozoa,  to 
which  they  attribute  a  pathological  significance.d 

"  The  dispersion  of  the  morbid  poison"  writes  Hirsch,e  'k  takes  place 
either  by  the  smallpox  patients  themselves,  or  through  the  medium  of 
other  persons,  or  of  articles  to  which  it  clings.  It  has  been  con- 
clusively proved  by  very  numerous  and  unambiguous  observations 
that  an  atmosphere  of  smallpox  poison  develops  around  the  sick, 
especially  when  they  are  crowded  in  close  rooms  ;  or,  in  other  words, 
that  the  air  may  become  a  carrier  of  the  contagion,  so  that  the 
latter  can  be  spread  by  the  atmospheric  currents  within  a  small 
range.  There  is  certainly  no  mathematical  expression  to  be  found 
for  the  extent  of  that  range ;  at  the  utmost,  it  extends  no  farther 
than  the  immediate  surroundings  of  the  sick." 

Sir  Thomas  Watson  f  mentions  a  remarkable  instance  of  smallpox 

a  Manual  of  Bacteriology.     London:  H.  K.  Lewis,  1887.     Page  203. 

b  The  Greek  letter  /j.  represents  one-thousandth  of  a  millimetre  {/j.  =  (VOOl), 
and  is  the  sign  of  a  micro-millimetre  or  micron. 

c  Gk.  aTpewrds,  pliant.  Hence  chain-armour.  Streptococci  are  micrococci 
which  arrange  themselves  in  chains. 

d  Clinical  Diagnosis.  By  Dr.  Rudolph  v.  Jaksch.  Translated  by  James 
Cagney,  M.A.,  M.D.     London:  Charles  Griffin  &  Co.     1890.     Page  35. 

e  Loc.  cit.     Page  152. 

{ Lectures  on  Practice  of  Medicine.  Second  Edition.  London,  1838.  Vol.11., 
786. 


74  SMALLPOX. 

being  caught  from  the  dead  body.  The  corpse  of  a  man  who  had 
died  of  the  disease  was  brought  into  Mr.  Caesar  Hawkins'  dissecting- 
room  in  Windmill-street,  London,  with  the  result  that  four  students 
took  the  disease,  although  only  one  had  touched  the  body. 

In  a  discussion  on  the  mode  of  preventing  the  spread  of  epidemic 
disease  from  one  country  to  another,  in  the  Section  of  Preventive 
Medicine  at  the  Seventh  International  Congress  of  Hygiene,  London, 
1891,  Dr.  Hewitt,  of  Minnesota,  U.S.A.,  recorded  a  still  more 
striking  case,  in  which  a  female  immigrant  attended  a  smallpox 
patient  on  board  ship  while  crossing,  the  Atlantic  from  Liverpool 
to  New  York,  then  doffed  and  put  by  her  clothes,  which  she  again 
began  to  wear  some  time  afterwards  while  attending  a  sick  child  in 
a  distant  part  of  the  country,  with  the  result  that  this  child  sickened 
of  smallpox,  the  disease  spreading  until  the  fatal  cases  numbered 
100.  All  the  time  the  woman,  whose  clothes  spread  the  disease, 
remained  perfectly  well  and  free  from  smallpox. 

The  experience  of  recent  epidemics — those  of  1871-73  and  of 
1876-79 — in  the  British  Islands  proves  that  the  striking  distance 
of  smallpox  is  considerable — certainly  much  greater  than  that  of 
typhus  fever. 

In  his  "Manual  of  Public  Health," a  Mr.  A.  Wynter  Blyth 
observes  :  "  The  usual  spread  of  smallpox  is  from  person  to  person, 
but  from  inquiries  which  have  taken  place  as  to  the  influence  of 
smallpox  hospitals  upon  a  surrounding  population,  and  the  expe- 
rience of  the  Sheffield  epidemic  (of  1887-1888),  it  is  certain  that 
the  infection  can  strike  at  a  distance.  Whether  the  contagious 
particles  are  conveyed  by  the  air  itself,  or  by  the  medium  of  the 
common  household  fly  or  other  insects,  the  important  fact  remains 
that  infection  may  travel  far.  The  influence  of  the  Sheffield 
Hospital  could  be  distinctly  traced  for  a  circle  of  4,000  feet ;  for 
instance,  the  following  percentages  of  households  attacked  at 
successive  distances  from  the  hospital  are  given  in  the  original 
a  London  :  Macmillan  &  Co.     1890.     Page  369. 


SMALLPOX.  75 

Report  (by  Dr.  Barry,  Inspector  of  the  Local  Government  Board 
for  England)  a  : — 

0-1,000  ft.     1-2,000  ft.     2-3,000  ft.     3-4,000  ft.     Elsewhere. 

1-75  '50  -14  -05  -02 

This  possibility  of  smallpox  spreading  by  aerial  infection  increases 
greatly  both  the  hospital  difficulty  and  that  of  individual  isolation." 

There  can  be  no  doubt  that  the  chief  stages  of  infectiveness  in 
smallpox  are  the  earliest  period  of  suppuration  (Curschmann),b  and 
the  Stadium  Decrustationis  of  Hebra — the  stage  of  desiccation,  or 
scabbing. 

Dr.  William  Heberden,  in  his  "  Commentaries  on  the  History 
and  Cure  of  Diseases,"0  says :  "  Many  instances  have  occurred  to 
me  which  show  that  one  who  has  never  had  the  smallpox  may 
safely  associate,  and  even  lie  in  the  same  bed  with,  a  variolous 
patient,  for  the  two  or  three  first  days  of  the  eruption,  without  any 
danger  of  receiving  the  infection.  One  woman  continued  to  suckle 
her  infant  for  two  days  after  the  smallpox  had  begun  to  appear 
upon  her ;  and  the  child  being  then  removed  escaped  the  distemper 
for  that  time,  but  was  unquestionably  capable  of  being  infected, 
because  he  catched  it  about  a  year  and  half  after." 

Clinical  History. — For  convenience  of  description  we  may  divide 
the  course  of  smallpox  into  five  stages — (1.)  Incubation ;  (2.) 
Invasion ;  (3.)  Eruption ;  (4.)  Secondary  Fever ;  (5.)  Desiccation 
and  Desquamation. 

I.  Stage  of  Incubation. — This  begins  with  the  reception  of  the 
virus  into  the  system  and  ends  at  the  appearance  of  the  earliest 
symptoms.  Its  average  duration  is  12  days,  except  in  cases  of 
inoculation,  when  it  is  only  8  days,  or  still  shorter — 18  hours, 
according  to  Curschmann.  As  a  rule,  there  are  no  symptoms  in 
this  stage,  but  towards  its  close  the  patient  probably  feels  unwell 
and  out  of  sorts — what  the  French  aptly  call  malaise. 

"■Report  of  an  Epidemic  of  Smallpox  at  Sheffield,  1887-8.  By  Dr.  Barry, 
Local  Government  Board.     London,  1889. 

b  Cf.  Von  Ziemssen's  Cyclopcedia  of  the  Practice  of  Medicine.  Art.  "  Small- 
pox." By  Heinrich  Curschmann,  of  Giessen.  London  :  Sampson  Low, 
Marston,  Low,  &  Searle.     1875.     Vol.  II. 

c  London  :  T.  Payne.     Second  Edition.     1803.     Page  437. 


76 


SMALLPOX. 


II.  Stage  of  Invasion. — Smallpox  sets  in  suddenly  and  with 
violence.  As  is  usual  in  febrile  disorders,  the  earliest  symptoms 
are  connected  with  the  nervous  system.  They  are  rigors,  varying 
from  a  mere  feeling  of  chilliness  to  a  downright  shivering  fit,  with 
chattering  teeth,  pallor,  blueness  of  the  extremities,  and  "goose- 
skin  "  {cutis  anserina),  and,  in  young  children,  convulsions.  More 
or  less  intense  pain  is  complained  of  in  the  lumbar  region,  or  in  the 
centre  of  the  sacrum  (rachiafgia),  apparently  due  to  hyperemia  of 
the  spinal  cord,  for  it  is  almost  always  relieved  by  haemorrhage, 
natural  or  induced.  Rheumatoid  pains  in  the  limbs  are  also  often 
felt,  so  that  the  question  of  acute  rheumatism  has  had  to  be  taken 
into  account  in  the  diagnosis  (Hilton  Fagge).  Severe  headache, 
often  delirium,  and  sometimes  partial  paraplegia,  numbness,  retention 
or  incontinence  of  urine  and  incontinence  of  faces,  may  be  also  present. 
In  children,  diarrhoea,  sleepiness  or  drowsiness  and  stupor  may  occur. 

On  the  first  or  second  day  the  temperature  rises  to  a  considerable 
height  (104°F.=40°  C,  seldom  below  this,  sometimes  above  it, 
even  to  105  8°  F.=41°  C. — Wunderlich).  The  maximal  tempera- 
ture {fastigium  or  acme)  is  usually  reached  shortly  before  the  rash 
appears  on  the  third  day.  This  initial  fever  is  called  the  Prodromal 
Fever,  because  it  runs  before,  or  precedes  the  appearance  of  the 
rash.a  The  other  most  prominent  symptoms  are  also  due  to  the 
influence  of  the  poison  on  the  nervous  system  ;  they  are — pain  in  the 
epigastrium,  or  pit  of  the  stomach,  nausea  and  often  vomiting,  con- 
stipation (except  in  children)  and  constant  profuse  sweating.  There 
are,  besides,  loss  of  appetite  {anorexia),  thirst,  furred  tongue,  very  foetid 
breath,  full  and  rapid  pulse,  and  prostration.  In  women,  menstrua- 
tion nearly  always  comes  on,  whether  the  period  is  due  or  not,  and 
it  is  generally  profuse  {monorrhagia).  All  these  symptoms  are,  as 
a  rule,  more  acute  and  prolonged  in  confluent  than  in  discrete 
smallpox. 

During  this  stage  accidental  rashes  are  apt  to  appear,  causing 
much  difficulty  in  diagnosis.  They  are  usually  erythematous  in 
character — if  diffuse,  resembling  scarlatina  or  erysipelas ;  if  spotty 

a  Prodromal — i.e.,  running  before,  preceding  ;  from  Gk.  itp6,  before  ;  Sp6/xos,  a 
course,  running,  race.  ~    .  ■ 


SMALLPOX.  77 

or  macular,  resembling  measles.  Rayer  long  ago  gave  to  these 
prodromal  rashes  the  name  of  Roseola. variolosa,  and  it  was  adopted 
in  1853  by  Eimer.  Dr.  Wilks  drew  attention  to  these  accidental 
rashes  in  "Guy's  Hospital  Reports"  for  1857  and  1861. 

These  prodromal  or  initial  erythematous  rashes  are  very  evanes- 
cent, they  usually  usher  in  an  attack  of  varioloid  or  mild  smallpox, 
and  so  have  no  little  prognostic  importance — but  they  are  not 
pathognomonic  of  smallpox,  as  they  show  in  other  specific  fevers 
also — for  example,  in  typhoid  fever  and  in  measles.  They  probably 
depend  on  a  reactive  inhibition  of  the  vaso-motor  system  of  nerves, 
brought  about  by  the  fever  poison.  Hebra  and  Trousseau,  as  well 
as  Curschmann,  seem  to  have  independently  remarked  that  the 
parts  affected  by  a  Roseola  variolosa  afterwards  remain  free  from 
the  proper  smallpox  rash.  This  observation  has  been  generally 
confirmed  by  subsequent  writers  (Hilton  Fagge). 

A  more  serious  phenomenon  is  the  development,  even  at  this 
early  stage,  of  petechia,  or  subcutaneous  extravasations  of  dissolved 
hsematin,  varying  in  size  from  a  pin's  head  to  a  pea  or  a  bean. 
These  purpuric  rashes  are  commonly  seen  in  the  brachial  and 
crural  triangles  of  Th.  Simon,  of  Hamburg a — the  former  em- 
bracing the  lateral  thoracic  region,  including  the  inner  side  of 
the  arm,  the  axilla,  and  the  pectoral  region ;  the  latter  embracing 
the  lower  abdominal  region,  including  the  hypogastrium,  the  groins, 
and  the  inner  aspect  of  the  thighs.  The  prognosis  in  such  cases  is 
generally,  but  not  necessarily,  more  grave. 

The  duration  of  the  stage  of  invasion  is  on  the  average  three 
days — as  a  rule,  it  is  prolonged  in  the  milder,  shortened  in  the 
severer  cases.  Sydenham,b  speaking  of  confluent  smallpox,  observes  : 
"  This  kind  of  smallpox  generally  comes  out  on  the  third  day,  some- 
times earlier,  but  scarce  ever  later,  whereas  the  distinct  appears  on 
the  fourth  day  inclusive  from  the  beginning  of  the  distemper,  or 
later,  but  very  rarely  before,  and  the  sooner  the  pustules  come  out 

aTh.  Simon,  Das  Prodromalexanihem  der  Pocken.  Arch,  fiir  Dermatologie 
und  Syphilographie.     II.  Jahrgang.     Page  347,  et  seq. 

b  The  Entire  Works  of  Dr.  Thomas  Sydenham.  By  John  Swan,  M.D., 
London  :    F.  Newbery.     1769.     Page  105. 


78  SMALLPOX. 

before  the  fourth  day  the  more  they  run  together.''  To  the  same 
effect,  Boerhaave  wrote a :  "  Most  practitioners  observe  that  th>i 
slower  the  smallpox  come  out,  the  milder  they  prove  and  the  better 
they  ripen.  Those  appearing  on  the  first  day  of  the  illness  are 
esteemed  the  worst  kind,  those  on  the  second,  milder,  those  on  the 
third  still  more  gentle,  and  on  the  fourth,  the  most  favourable." 

Trousseau  and  nearly  all  modern  authorities  concur  in  this 
view,  but  Curschmann  thinks  it  is  not  warranted  for  all  epidemics. 
It  may,  however,  be  accepted  as  a  sound  working  proposition, 
although  there  is  one  striking  exception  to  it.  In  consequence  of 
great  organic  lesions— as  Sydenham  writes,  ob  atrocius  aliquod 
symptoma — the  eruption  may  be  retarded  till  the  sixth  or  seventh 
day  both  in  distinct  and  confluent  cases — "  malo  semper  omine." 
Trousseau  b,  in  illustration,  mentions  the  case  of  a  woman,  aged  30, 
in  whom  the  rash  did  not  appear  until  the  fifth  day.  At  the 
beginning  of  her  attack  of  smallpox  she  had  all  the  symptoms  of 
sporadic  cholera — vomiting,  purging,  cramps,  general  coldness, 
blanching  of  the  mucous  membranes,  dry,  cold  tongue,  injection  of 
the  conjunctiva,  and  a  dull  appearance  of  the  cornea.  The  choleraic 
symptoms  ceased  on  the  fourth  day,  and  on  the  fifth  the  eruption  of 
smallpox  appeared.  Again,  a  long  experience  in  the  wards  of 
Cork-street  Fever  Hospital,  Dublin,  has  led  me  to  the  conclusion 
that  a  purpuric  or  hemorrhagic  tendency  early  in  smallpox  post- 
pones— it  may  be  indefinitely — the  appearance  of  the  true  variolous 
exanthem.     To  this  subject  it  will  be  necessary  to  return. 

III.  Stage  of  Eruption. — The  true  exanthem,  or  rash,  of 
smallpox  appears  first  on  the  head,  neck  and  face,  and  about  the 
wrists,  next  on  the  trunk,  lastly  on  the  lower  extremities.  In 
severe  cases,  as  has  been  already  mentioned,  it  shows  itself  on  the 
second  or  even  on  the  first  day ;  in  mild  cases  its  coming  may  be 
postponed  until  the  fourth  day.  The  usual  day  for  its  appearance  is 
the  third,  inclusive,  from  the  earliest  symptoms.    When  the  "  pocks  " 

a  Boerhaave.  Prax.  med.  "Vol.  V.,  page  302.  [Quoted  by  Sydenham,  loc. 
cit.l 

b  Glinique  Midicale  de  l'H6tel  Dieu  de  Paris.  Paris  :  J.  B.  Bailliere  et  Fils. 
1865.     Deuxieme  Edition.     Tome  premier,  page  6. 


8MALLP0X.  79 

fulfil  their  whole  life-history,  they  are   seen  to  pass  through  the 
following  stages  of  development : — 

1.  Specks  of  Hypersemia,  like  the  fine  pricks  made  with  a 
needle,  and  sometimes  like  recent  fleabites  (first  day  of  rash). 

2.  Papules,  or  Pimples,  such  as  are  met  with  in  persons  affected 
with  lichen  or  prurigo  (Trousseau),  at  first  slightly  raised,  then 
conical,  already  hard  or  "  shotty  "  to  the  touch,  feeling  like  grains 
of  shot  underneath  the  skin  (second  and  third  days  of  the  rash). 

3.  Vesicles  filled  with  a  clear,  transparent  fluid  at  first,  but 
which  quickly  becomes  lactescent  or  milk-like.  "  By  the  fourth 
or  fifth  day  of  the  eruption  (seventh  or  eighth  of  the  disease)," 
continues  Dr.  Hilton  Fagge,  "  the  vesicle  is  generally  as  large  as  a 
split  pea,  hemispherical  in  form,  and  opaline  in  appearance." 

4.  Pustules  formed  by  a  further  change  in  the  contents  of  the 
vesicles  in  which  young  cells  increase  and  multiply,  causing  them 
to  assume  a  more  and  more  opaque  and  yellow  appearance,  and 
to  increase  quickly  in  size  (sixth  and  seventh  days  of  the  rash). 
About  this  time  a  central  depression  is  found  in  these  pustules. 
This  is  the  so-called  umbilicus,  at  the  bottom  of  which  the  opening 
of  a  hair  follicle  or  sweat  gland  is  frequently  observed  (Curschmann). 

This  carries  us  on  to  the  10th  day  of  the  disease,  when  the  rash 
has  reached  its  fullest  development.  The  pustule,  when  at  its 
height,  is  often  quite  hemispherical,  the  umbilicus  having  disap- 
peared in  consequence  of  the  rupture  of  the  retinaculum  which 
formed  it.  These  pustules  are  really  small  abscesses.  They 
become  extremely  painful,  and  the  pain  is  accompanied  by  great 
swelling  of  the  affected  parts— greatest  where  the  tissues  are 
loosest  or  most  relaxed,  as  in  the  eyelids  and  lips,  and  about  the 
prepuce.  In  the  confluent  variety,  about  to  be  described,  the  face 
swells  to  a  shapeless  mass,  rendering  the  patient  absolutely  unre- 
cognisable. 

Each  pustule  is  now  surrounded  with  an  inflammatory  zone  or 
areola,  called  the  halo  of  the  pustule. 

This  period  of  fullest  development  of  the  rash  is  called  the  period 
of  maturation,  or  ripening,  It  lasts  about  three  days  and  is  fol- 
lowed by — . 


;80  SMALLPOX. 

5.  The  last  stage  in  the  life  history  of  the  eruption,  that  of 
desiccation — the  drying-up  of  the  pustules — and  the  formation  of 
crusts  or  scabs. 

IV,  Stage  of  Desiccation. — Even  before  the  eleventh  day  an 
exudation  of  a  sticky  fluid  takes  place,  and  a  yellowish  matter  like 
thick  honey  oozes  from  the  surface  of  the  pustules.  This,  together 
with  their  other  contents,  speedily  dries  up,  first  in  the  centre,  and 
brownish  scabs  are  formed,  which  are  at  first  adherent,  but  after- 
wards fall  off  in  from  3  to  6  days,  leaving  elevations  or  projections 
of  a  violet  red  hue,  like  a  cold  skin. 

On  the  trunk  and  extremities,  where  desiccation  begins  later 
than  on  the  face,  the  pustules  frequently  burst  and  their  purulent 
contents,  soaking  into  the  bed  and  body  linen,  under  godecomposi- 
tion  upon  the  skin  and  in  the  clothing,  causing  an  overwhelming 
stench  about  the  11th  or  12th  day  of  the  disease.  This  occurs  in 
the  confluent,  not  in  the  discrete,  form.  With  the  drying-up  of 
the  pustules,  the  redness,  swelling,  and  tenderness  of  the  skin  sub- 
side, the  eyes  reopen,  the  nostrils  are  cleared,  and  the  features  of 
the  patient  become  once  more  recognisable. 

V.  Stage  of  Desquamation. — After  this,  successive  scales  of 
epidermis  form  and  peel  off — a  process  which  is  called  desquama- 
tion— ultimately  leaving  a  small  white  puckered  scar  (cicatrix) 
should  the  variolous  inflammation  of  the  skin  (dermatitis)  have 
dipped  deep  and  involved  the  papillary  portion,  or  cutis  vera.  When 
every  scab  has  fallen  off  and  desquamation  has  ceased,  the  patient 
may  be  considered  free  from  infection. 

About  the  same  time  that  the  rash  of  smallpox  shows  on  the 
skin,  a  true  variolous  exanthem  develops  upon  the  mucous  mem- 
branes in  general.  Of  this  we  have  ocular  proof  in  the  case  of 
those  parts  of  the  mucous  membranes  which  are  visible  and  are 
most  exposed  to  the  air.  Thus,  the  conjunctivae,  the  mucous 
membranes  of  the  nose,  mouth,  pharynx  and  adjacent  parts,  are 
nearly  always  affected.  Thence  the  rash  extends  through  the  whole 
system  of  mucous  membranes,  invading  the  larynx,  trachea,  and 
bronchi  in  one  direction,  the  oesophagus,  stomach,  and  intestines  in 
another.    It  is  true  that  Curschmann  states  that  it  is  very  doubtful  if 


SMALLPOX.  81 

real  pustules  are  ever  formed  in  the  stomach  ami  intestines,  although 
they  have  been  described  by  the  older  authors  (Robert,  in  his  account 
of  an  epidemic  in  Marseilles).  He  adds  that  they  are  seen  only  in  the 
lowest  part  of  the  rectum,  close  to  the  anus.  Nevertheless,  for  many 
years  I  have  had  an  opportunity  of  illustrating  my  lectures  on  Small- 
pox by  exhibiting  a  series  of  beautiful  original  drawings,  by  the  late 
Mr.  J.  Conolly,  of  the  pathology  of  this  disease.  These  drawings 
show  the  entire  respiratory  and  digestive  tracts  thickly  beset  with 
a  variolous  eruption,  presenting  itself  as  whitish  or  pearly-gray 
elevations  upon  a  reddened  base,  with  abrasions  or  large  irregular 
excoriations  of  the  mucous  membrane.  During  life  the  presence 
of  such  an  eruption  is  evidenced  by  such  symptoms  as  deafness, 
due  to  blocking  of  the  Eustachian  tubes  (Wendt) ;  hoarseness  or 
aphonia ;  cough  and  dyspnoea ;  dysphagia,  or  difficulty  of  degluti- 
tion ;  diarrhoea. 

According  to  Curschmann.  true  pocks  upon  the  serous  mem- 
branes are  fables  belonging  to  antiquity. 


82 

CHAPTER  VIII. 

Smallpox  {continued). 
Classification  and  Varieties. 

Classification  of  Smallpox  based  upon  the  distribution  and  amount  of  the 
Rash  :  Variola  discbeta,  oonfluens,  coh^rens,  corymbosa. — Symptoms  of 
Confluent  Smallpox  :  its  mortality  and  sequelae. — Meaning  of  the  terms  "  Semi- 
confluent"  or  "Coherent,"  and  "Corymbose,"  Smallpox. — The  latter  said  to 
be  a  very  fatal  variety. 

Before  describing  the  behaviour  of  the  temperature  during  the 
eruptive  and  subsequent  stages  of  Smallpox,  we  may  refer  to  a 
classification  of  the  varieties  of  the  disease  based  upon  the 
distribution  and  amount  of  the  rash,  which  has  been  handed  down 
from  the  time  of  Sydenham,  and  has  received  universal  acceptance. 

Under  all  circumstances,  whether  modified  or  unmodified,  Small- 
pox appears  under  two  principal  forms — Discrete  or  Distinct,  and 
Confluent.  The  first  of  these  is  generally  free  from  danger  ;  the 
latter  is  one  of  the  most  terrible  and  fatal  of  diseases.  Of  confluent 
smallpox  two  modified  varieties  are  described — namely,  (1)  Semi- 
confluent,  or  Coherent  Smallpox ;  and  (2)  Corymbose  Smallpox. 

Variola  discreta,  vel  distincta,  is  the  name  given  to  those  cases 
in  which  the  rash  is  sparse  or  scanty,  the  several  papules  or  pustules 
being  more  or  less  widely  separated  from  each  other.  Hence  the 
term  Discrete  (from  Lat.  discerno,  1  separate).  In  this  form  the  initial 
symptoms  are,  as  a  rule,  less  acute  and  less  persistent,  and  the 
rash  not  infrequently  stops  short  of  the  pustular  stage  {Variola 
crystallina). 

Variola  confluens  is  the  term  applied  to  those  cases  in  which 
the  rash  overruns  the  entire,  or  nearly  the  entire,  surface  of  the 
body,  and  invades  the  mucous  membranes  also  with  great  severity. 
The  symptoms  of  the  invasion  stage  are  all  intensified,  and  the  rash 
appears  as  early  as  the  second  day.  As  additional  and  very 
characteristic  symptoms,  Trousseau  mentions,  (1)  persistent  diarrhoea, 
both  in  adults  and  in  children ;  (2)  profuse  salivation  in  adults, 


SMALLPOX.  83 

resulting  either  from  parotitis,  or,  as  a  reflex  symptom,  from 
inflammation  of  the  mucous  memhranes  of  the  mouth — stomatitis 
(Curschmann)  ;  (3)  great  tumefaction  of  the  face  and  eyelids,  so  that 
the  latter  sometimes  burst  or  slough  ;  and  (4)  most  painful  swelling 
of  the  hands  and  feet. 

Salivation,  or  ptyalism,  sets  in  early,  and  is  extraordinarily  pro- 
fuse. According  to  Trousseau,  from  one  to  two  litres  (that  is,  from 
35  to  70  fluid  ounces)  of  clear,  but  ropy  or  viscid,  saliva  may  flow 
from  the  patient's  mouth  within  twenty-four  hours,  and  this  ptyalism 
is  accompanied  by  a  burning,  unquenchable  thirst. 

To  omit  special  mention  of  the  delirium  of  confluent  smallpox 
would  be  misleading.  In  the  epidemics  of  1871  and  1878,  in  Cork- 
street  Fever  Hospital,  Dublin,  the  occurrence  of  delirium  was  one 
of  the  commonest  and  most  striking  features  of  the  disease.  It 
was  often  violent  and  noisy  (delirium  ferox)  ;  or  busy,  with  extreme 
muscular  agitation  (delirium  tremens) ;  but  in  the  later  stages  it 
assumed  more  of  the  low  muttering  type  (typhomania  of  Galen). 
Both  at  the  Meath  Hospital  and  at  Cork- street  Hospital,  attempts 
at  suicide  were  made  by  delirious  smallpox  patients,  and  homicide 
has  happened  before  now  as  a  result  of  the  same  delirium  ferox. 
Huxham,  in  his  classical  "  Essay  on  Fevers,"  a  graphically  describes 
the  rash  in  these  cases  as  consisting  of  pocks  which  are  "pale, 
crude,  pitted,  and  sessile." 

The  face  is  covered  with  pustules,  which  run  together  so  that 
the  epidermis  is  raised  by  a  milky  sero-purulent  secretion,  and  the 
face  seems  as  if  it  were  dipped  in  tallow  or  covered  with  a  mask  of 
parchment — uPergameno3  speciem  visu  horrendam  (cutis  faciei)  exhibet? 
as  Morton  said  in  his  "  Pyretologia."b  It  is  right  to  mention  that, 
in  confluent  smallpox,  while  the  face  and  hands  may  be  absolutely 
covered  with  pocks,  in  other  parts  of  the  body  the  eruption  may  be 
more  or  less  discrete,  the  amount  and  intensity  of  the  pustulation 
seemingly  being  in  direct  proportion  to  the  vascularity  and  inflam- 
matory state  of  the  surface.  This  was  pointed  out  several  years 
ago  in  an  admirable  paper  on  the  "  Treatment  of  Smallpox  "  by  the 

a  London  :  J.  Hinton.     1764.     Page  127. 
b  London.     1692. 


84  SMALLPOX. 

late  Dr.  William  Stokes,a  Regius  Professor  of  Physic  in  the  Uni- 
versity of  Dublin.  Of  this  fact  we  have  two  proofs — in  the  first 
place,  portions  of  skin  which  have  been  subjected  to  mechanical 
or  chemical  irritation,  either  before  infection  or  during  the  stage 
of  incubation,  invariably  throw  out  a  veiy  abundant  pustular,  and 
frequently  a  confluent,  eruption  even  in  discrete  cases  of  smallpox. 
Conversely,  and  secondly,  where  the  vascularity  of  a  part  has  been 
reduced  by  pressure,  local  depletion,  or  removal  of  irritation  by 
poulticing,  bathing,  or  other  means,  the  eruption  of  smallpox  is 
distinct  even  in  confluent  cases.b 

The  mucous  membranes,  like  the  skin,  are  the  seat  of  a  closely 
set  rash  in  confluent  smallpox,  and  very  dangerous  forms  of  second- 
ary inflammation  are  apt  to  place  the  patient's  life  in  imminent  peril. 
Glossitis  variolosa,  or  inflammation  of  the  tongue  ;  diphtheria,  acute 
oedema  of  the  glottis,  intense  and  wide-spread  bronchitis  and 
pneumonia;  violent,  uncontrollable  vomiting,  retching,  and  diar- 
rhoea, are  among  the  evidences  we  have  of  the  serious  engagement 
of  the  mucous  membranes. 

Towards  the  close,  should  the  patient  survive,  multiple  pyaemic 
abscesses,  erysipelas,  and  even  gangrene  may  occur  in  those  parts 
of  the  integument  where  the  confluence  is  most  pronounced. 

The  mortality  is,  of  course,  very  great  in  this  form  of  the 
disease,  at  any  stage  of  which  the  patient  may  succumb.  In  some 
epidemics,  according  to  Trousseau,  half  the  patients  die ;  in  others, 
four-fifths,  and  in  others,  less  fatal,  one-third  of  those  attacked 
perish.  It  is,  therefore,  the  most  deadly  of  all  pestilences,  yellow 
fever  and  cholera  not  excepted.  The  terrible  feature  of  smallpox 
is  that  it  kills  not  only  in  the  acute  stage,  by  dissolution  of  the 
blood  or  by  the  intensity  of  the  fever,  but  also  in  the  later  stages 
and  in  convalescence.  The  most  fatal  epoch  is  about  the  eleventh 
or  twelfth  day,  but  even  far  on  in  the  stage  of  desiccation  death 
not  infrequently  results  from  exhaustion,  or  pyaemia,  or  some  other 
complication.     I  will  return  to  the  subject  of  mortality  later  on. 

a  See  the  Dublin  Journal  of  Medical  Science,  Vol.  LIIL,  p.  9.     Dublin  : 
Fannin  &  Co.     1872. 
b  Cf.  Stokes,     hoc.  cit. 


SMALLPOX.  85 

Should  confluent  smallpox  end  in  recovery,  convalescence  is  very 
tedious,  and  is  frequently  interrupted  by  serious  sequelae,  of  which 
an  "  acute  furuncular  diathesis,"  as  Trousseau  calls  it,  is  one  of  the 
commonest  and  most  troublesome.  It  shows  itself  in  the  formation 
of  successive  crops  of  most  painful  boils,  and  of  more  or  less  deep- 
seated  abscesses. 

In  the  stage  of  desiccation  large,  ecthymatoid  crusts  form  upon 
the  ulcerated  surface  of  the  skin.  These  become  detached,  leaving 
the  dermis  scooped  out.  Successive  layers  of  thinner  and  thinner 
crusts  form,  and  are  shed  during  two,  three,  or  four  weeks,  the 
idcerations  finally  cicatrising,  leaving  the  rugged  scars  which  seam 
the  faces  of  those  who  have  passed  through  confluent  smallpox. 
To  this  disfigurement  the  term  "  pitting"  has  been  applied.  It  is 
especially  unsightly  about  the  nose,  the  borders  of  the  alae  nasi 
appearing  indented,  and  the  bridge  and  tip  of  the  nose  split  and 
torn. 

With  the  separation  of  the  scabs,  or  sometimes  later,  the  hair 
commonly  falls  off,  in  some  cases  in  handfuls.  If  the  variolous 
inflammation  of  the  scalp  has  dipped  deeply  and  involved  the  hair 
follicles  to  any  great  extent,  the  resulting  alopecia,  or  baldness,  may 
be  permanent.  More  usually,  the  hair  grows  again,  in  a  few  cases 
more  luxuriantly,  if  less  smoothly,  than  before.  It  is  not  usual  for 
the  nails  to  fall  off  after  smallpox,  although  the  atrophic  furrows 
across  them,  described  and  figured  by  A.  Vogel,  and  mentioned  by 
Murchison8  as  occurring  in  typhus  fever,  are  not  infrequently 
observed. 

I  have  stated  above  that  two  modifications  of  confluent  smallpox 
are  recognised  as  regards  the  distribution  of  the  rash.  These  are 
the  semi-confluent  and  the  corymbose  varieties. 

The  term  Variola  semi-confluens,  or  Coherent  Smallpox,  is 
applied  to  those  cases — (1)  in  which  the  pustules  touch  each  other 
without  coalescing,  or  (2)  in  which  the  eruption  is  confluent  on  and 
about  the  face,  and  more  or  less  discrete  elsewhere. 

&A  Treatise  on  the  Continued  Fevers  of  Great  Britain.  Third  Edition.  1884. 
Page  136. 


86  SMALLPOX. 

Variola  corymbosa  is  a  term  applied  to  those  cases  where  the 
pustules  are  confluent  in  patches,  or  clutters  (/copu/A/3o?,  «  cluster  of 
fruit),  these  being  separated  by  intervals  of  unaffected  skin.  Vascular 
parts,  like  the  axilla?,  groins,  and  popliteal  spaces,  are  often  the  seat 
of  such  an  eruption.  Hilton  Fagge  says  that  he  never  saw  a  case 
of  corymbose  smallpox,  but  there  is  a  beautiful  drawing  of  it  in  the 
collection  of  J.  Conolly's  illustrations  of  smallpox  observed  in  the 
Hardwicke  Fever  Hospital,  Dublin,  to  which  I  have  already  alluded. 
According  to  Marson,  formerly  of  the  London  Smallpox  Hospital, 
this  is  a  very  fatal  variety  of  smallpox,  the  mortality  reaching 
41  per  cent.  Strangely  enough,  in  the  London  Smallpox  Hospital 
it  was  scarcely  less  destructive  to  vaccinated  persons  than  to  those 
who  were  unprotected  (Hilton  Fagge). 


87 


CHAPTER  IX. 

Smallpox  (continued). 

Temperature — Varieties — Complications — Pathology — 
Diagnosis — Prognosis. 

Temperature  :  Two  distinct  Types  of  Fever  in  Smallpox — viz.  1.  A  brief 
continuous  Fever  ;  2.  A  relapsing  Fever. — Prodromal  or  Initial  Fever. — 
Secondary  Fever,  or  Fever  of  Suppuration  or  of  Maturation. — Hyperpyrexial 
Temperature  in  Fatal  Cases. — Varieties  op  Smallpox  :  Discrete,  Confluent, 
Benign  or  Varioloid — 1.  Variola  sine  Exanthemate,  2.  V.  cornea  (Hornpox), 
3.  V.  verrucosa  (Wartpox)  ;  Malignant  (V.  maligna) — 1.  Purpuric,  2.  Hsemor- 
rhagic  (Purpura  variolosa),  3.  V.  haemonhagica  pustulosa  of  Curschmann, 
V.  nigree  of  Sydenham,  V.  cruentse.— Table  op  the  varieties  op  Smallpox. 
Complications  and  Sequels,  affecting  the  skin,  eyes,  ears,  nose,  tongue, 
larynx,  respiratory  organs,  digestive  organs,  circulatory  system,  kidneys, 
nervous  system,  genitals,  blood,  joints. — Pathology  :  Morbid  anatomy  and 
histology. — Diagnosis,  Prognosis,  and  Mortality. 

Temperature. — As  pointed  out  by  Wunderlich,a  the  fever  in 
variola  exhibits  two  distinct  types,  which  closely  correspond, 
however,  at  their  commencement. 

I.  One  of  these  types  is  a  brief  continuous  fever,  belonging  in 
particular  to  the  milder  forms  of  variola  discreta  and  to  most  cases 
of  varioloid  or  modified  smallpox,  occurring  chiefly  although  not 
exclusively  in  vaccinated  or  inoculated  persons.  This  is  the  so- 
called  Prodromal  or  Initial  Fever  of  the  stage  of  invasion.  In 
the  forms  of  the  disease  just  mentioned,  this  continuous  fever  both 
begins  and  usually  completes  the  febrile  movement.  The  maximal 
temperature  of  the  initial  or  prodromal  fever  is  rarely  less  than 
104°  F.  (40°  C.) ;  it  generally  exceeds  this,  reaching  even  106°  F. 
(41'1°  C.).  This  great  height  is  quickly  attained,  generally  on  the 
second  day.  Soon  after  the  true  rash  of  smallpox  appears,  the 
temperature  falls  more  or  less  rapidly — usually  from  the  fourth  to 
the  8ixth  day.     The  defervescence  is  either  rapid  and  continuous, 

a  A  Manual  of  Medical  Thermometry.  New  Sydenham  Society.  1871. 
P.  337. 


88  SMALLPOX. 

or  slower  and  interrupted  by  a  moderate  evening  exacerbation.  In 
cases  of  uncomplicated  varioloid  and  of  mild  discrete  smallpox  this 
defervescence  is  complete  and  final. 

The  fall  of  temperature  which  occurs  with  the  coming  out  of 
the  rash  of  smallpox  is  pathognomonic  of  this  disease,  and  is 
therefore  of  the  first  importance  in  diagnosis.  It  is  exactly  the 
converse  of  the  behaviour  of  the  temperature  in  measles,  in  which  the 
fever  is  moderate  up  to  the  appearance  of  the  rash,  and  then  becomes 
more  and  more  intense  until  the  rash  is  most  fully  developed. 

It  should  be  borne  in  mind  that  the  initial  or  prodromal  fever  is 
often  very  severe  even  in  the  mildest  cases. 

II.  The  other  type  of  fever  in  smallpox  is  a  relapsing  type, 
which  is  characteristic  of  true  smallpox  in  its  severer  and  confluent 
forms.  The  falling  temperature  after  the  prodromal  stage  in  this 
case  either  never  reaches  the  normal  line,  remaining  at  subfebrile 
(99-5°  to  100-4°  F.),  or  even  at  febrile  (points  100.4°  to  102-2°  R 
in  the  morning,  rising  to  103°  F.  in  the  evening) ;  or  the  normal 
temperature  is  reached,  if  at  all,  tediously,  and  defervescence  is  by 
lysis. 

Then,  with  the  beginning  of  the  pustulation,  or  ripening  {matura- 
tion) of  the  exanthem  the  temperature  again  begins  to  rise,  ushering 
in  a  Secondary  Fever — the  Fever  of  Suppuration  or  of  Maturation 
("  Eiterungsfieber "  of  the  Germans)  as  it  is  called — which  is  of 
indefinite  duration  and  varies  in  intensity  according  to  the  severity 
of  the  disease.  In  a  sharp  attack  of  discrete  or  semi-confluent 
smallpox,  the  temperature  in  this  secondary  fever  rarely  exceeds 
103°  or  104°  F.  There  are  morning  remissions,  and  the  duration 
is  only  a  few  days.  In  bad  confluent  smallpox,  on  the  other  hand, 
the  fever  runs  very  high,  presenting  sometimes  a  remittent  course 
with  marked  exacerbations,  sometimes  a  continuous  range  with 
occasional  isolated  elevations  or  spikings  of  temperature. 

Eepeated  elevations  of  temperature  above  104°  F.  (40°  C.)  during 
this  fever  of  suppuration,  or  maturation,  are  a  sign  of  great  danger. 
In  cases  which  tend  towards  recovery,  defervescence  takes  place 
by  an  irregular  lysis.  In  fatal  cases,  hyperpyrexial  temperatures 
(107*6°  F.=42°  C.)  are  wont  to  occur  before,  at  the  moment  of, 


Plate  J. 
CHARTS  OF  TEMPERATURE  RANGES  IN  SMALLPOX. 


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SMALLPOX.  89 

or  even  after  death.  Th.  Simon,  of  Hamburg,  has  published  a  two 
cases  in  which  the  temperature  after  death  was  110750  and 
112-1°  F.  respectively.  In  Plate  IV.,  illustrating  his  work  on 
"  Medical  Thermometry,"  Wunderlich  includes  a  chart  of  the 
temperature  in  a  case  of  smallpox  fatal  in  the  suppurating  stage, 
in  which  the  thermometer  marked  109-2°  F.  shortly  before  death. 

The  accompanying  Temperature  Charts  are  from  cases  observed 
by  me  in  the  wards  of  Cork-street  Fever  Hospital,  Dublin,  and  the 
Meath  Hospital  and  County  Dublin  Infirmary.     [See  Plate  I.] 

Apart  from  the  classical  and  recognised  forms  of  Discrete  and 
Confluent  Smallpox,  we  meet  also  with  the  following  varieties  of 
the  disease : — 

1.  Variola  benigna  (Varioloid — Fr.  Variole  modif.ee).  This  is  a 
mild  and  abortive  form  of  smallpox  in  which  the  pocks  either  fail 
to  appear  at  all  (Variola  sine  exanthemate,  or  V.  sine  variolis), 
or  else  fail  to  pass  through  the  later  stages  of  their  development, 
stopping  short  at  the  papular  stage  (Variola  cornea  or  Hornpox), 
or,  if  reaching  the  vesicular,  drying  up  and  shrivelling  on  the  5th 
or  6th  day  of  the  eruption  (Variola  verrucosa,  or  Wartpox).  In 
other  cases  the  exanthem  passes  rapidly  and  imperfectly  through 
all  phases  of  its  development,  producing  more  or  less  dwarfed  forms 
of  the  pustules. 

Some  readers  may  be  sceptical  as  to  the  existence  of  a  Variola 
sine  variolis,  but  the  evidence  is  overwhelming  that  there  is  such  a 
form  of  smallpox.  After  a  well-marked  initial  stage,  the  disease 
aborts  and  the  patient  is  well  in  three,  four,  or  six  days  at  the 
latest.  Dr.  Hilton  Fagge  refers  to  one  instance  of  this  kind,  which 
was  attended  by  a  characteristic  roseola.  Another  example  of  it 
is  thus  recorded  by  Marson.  A  lady  walked  with  a  person  already 
affected  with  smallpox.  Twelve  days  afterwards  she  was  taken 
ill :  she  was  for  a  few  hours  delirious,  but  her  illness  passed  off 
without  eruption ;  twelve  days  later  still,  her  sister,  who  had  not 
been  out  of  the  house  for  three  months,  was  attacked  with  the 
same  disease,  which  ultimately  assumed  a  covflueni  form.  Curschmann 
mentions  the  case  of  a  woman  who  was  seized  with  shivering, 
a  ChariU  Anualen,  XIII.     Band  V. 


90  SMALLrOX. 

fever,  headache,  and  pain  in  the  back,  so  that — as  variola  was 
epidemic  at  the  time — she  seemed  without  doubt  to  be  passing 
through  the  initial  stage.  On  the  fourth  day  defervescence  occurred, 
no  rash  could  be  detected,  and  by  the  tenth  day  she  felt  perfectly 
well.  However,  she  gave  birth  to  an  infant,  which  was  covered 
with  an  early  eruption  of  smallpox.  This  afterwards  suppurated 
and  proved  fatal.8. 

In  the  case  of  the  so-called  wartpox,  also,  the  solid  part  of  the 
pock  remains  for  a  long  time,  presenting  the  appearance  of  a 
wart — hence  the  name,  "wart-pox"  (Latin — verruca,  a  wart). 

As  Curschmann  points  out,  Varioloid  is  nothing  more  than  a 
form  of  true  smallpox  with  a  milder  course  and  a  shorter  duration. 
Many  individuals  are  attacked  only  by  this  form  because  of  a 
naturally  slight  susceptibility  to  the  contagium  of  the  disease. 
Again,  when  the  immunity  gained  by  a  previous  attack  of  small- 
pox, or  from  a  previous  inoculation,  or  from  vaccination,  has 
become  impaired  through  lapse  of  time,  then  exposure  to  the 
poison  may  induce  an  attack  of  modified  smallpox  or  varioloid. 
There  can  be  no  question  that  this  mild  form  of  so  dreadful  a 
disease  as  smallpox  has  become  relatively  much  more  frequent 
since  vaccination  was  introduced  about  a  century  ago. 

As  stated  above,  Hebra,  Trousseau,  and  Curschmann,  all  con- 
sider that,  as  a  rule,  the  development  of  the  pocks  is  less  the  more 
extensive  is  the  initial  erythematous  eruption.  Viewed  in  this 
light  the  purely  erythematous  rashes  of  the  invasion  stage  come 
to  be  of  decided  value  in  prognosis.  I  have  already  said  that 
these  rashes  are  to  be  carefully  distinguished  from  the  petechia 
which  form  in  the  earliest  stage  of  some  cases  of  the  terrible 
purpuric  or  hsemorrhagic  smallpox  which  I  will  now  describe. 

2.  Variola  maligna — Variola  purpurica  vel  hemorrhagica. — 
Observations  of  some  three  thousand  cases  of  smallpox  in  two 
hospitals  and  two  epidemics  has  led  me  to  the  conclusion  that, 
apart  from  confluent  smallpox  in  which  the  patient's  life  is  en- 
dangered by  the  amount  of  suppuration  and  the  intensity  of  the 

a  The  Principles  and  Practice  of  Medicine.  By  the  late  Charles  Hilton 
Fagge,  M.D.,  F.R.C.P.     London  :  J.  &  A.  Churchill.    1886.    Vol.  L,  page  225. 


SMALLPOX.  91 

secondary  or  suppurative  fever,  Malignant  Smallpox  is  to  be 
recognised  under  two  forms — (1)  purpuric,  and  (2)  hsemorrhagic. 
These  forms  differ  merely  in  degree — in  both  the  blood  is  pro- 
foundly altered,  and  devitalised  to  such  an  extent  that  it  is  incapable 
of  throwing  out  or  developing  the  characteristic  eruption  of  small- 
pox. In  the  purpuric  variety  the  dissolution  of  the  blood  leads  to 
the  formation  of  petechias,  vibices  or  purple  streaks  or  blotches, 
and  ecchymoses — appearances  connected  with  the  skin  which  are 
sufficiently  well  known  and  do  not  require  further  definition. 

In  haemorrhagic  smallpox  the  dissolution  of  the  blood  is  carried 
still  further,  so  that  a  condition  of  acute  haemophilia  is  produced — 
the  ill-fated  patient  bleeds  from  every  pore  and  orifice  of  the  body. 
There  is  chemosis — he  may  even  weep  tears  of  blood.  There  is 
epistaxis — he  bleeds  from  the  lips  and  gums.  He  spits  or  coughs 
up  blood,  he  vomits  blood.  The  motions  from  the  bowels  are 
tarry.  Blood  pours  from  the  kidneys,  and  in  the  female  from  the 
genital  organs.  The  tongue  looks  as  if  it  was  parboiled,  and  there 
is  an  unquenchable  thirst.  Under  these  circumstances,  unless  the 
haemorrhage  is  staunched  by  turpentine  and  ergot,  or  ferric  chloride, 
or  pyrogallic,  gallic,  and  tannic  acids,  or  other  means,  death  speedily 
ensues — too  often  indeed  in  spite  of  all  that  human  skill  and  care 
can  do. 

One  of  the  most  extraordinary  as  well  as  the  most  painful  fea- 
tures of  this  deadly  malady  is  the  clearness  of  mind  which  often 
remains  with  the  unhappy  patient  almost  up  to  the  time  when  he 
draws  his  latest  breath.  There  is  in  some  instances  no  delirium,  no 
stupor,  no  dulling  of  the  intellect  whatever — the  victim  literally 
looks  death  in  the  face  in  full  possession  of  his  senses.  It  has 
happened  to  me  to  be  asked  by  a  patient  at  11  a.m.  how  long  he 
had  to  live,  and  that  patient  lay  dead  four  hours  afterwards. 

The  cessation  of  the  bleeding  may  bring  back  haemorrhagic 
smallpox  to  the  purpuric  form,  and  in  the  case  of  the  latter  variety 
of  malignant  smallpox  the  restoration  of  the  blood,  evidenced  by 
the  brightening  of  the  purpuric  spots,  may  be  followed  by  the 
tardy  development  of  a  copious  eruption  of  either  aborted  pustules 
(papules) — in  which  case  the  patient  happily  recovers  speedily,  and 


92  SMALLPOX. 

without  suffering  from  a  fever  of  maturation — or  true  and  fully- 
formed  pustules,  when  the  patient  has  still  to  run  the  gauntlet  of  a 
severe  attack  of  confluent  smallpox,  with  its  secondary  fever,  com- 
plications, and  sequele.  This  is  the  idea  of  malignant  smallpox 
and  its  varieties  which  I  have  formed  from  a  lengthened  expe- 
rience. 

Strong  muscular  men  and  pregnant  or  recently  delivered  women 
are  said  to  be  particularly  liable  to  fatal  hemorrhagic  smallpox, 
and  this  was  certainly  the  case  in  the  Dublin  epidemics  of  1871 
and  1878.  Curschmann,  however,  states  that  he  has  often  seen  this 
variety  of  the  disease  in  delicate  persons  and  in  drunkards  also. 

According  to  Marson  the  blood  in  this  form  of  smallpox  is 
"poisoned  from  the  very  first  and  is  rendered  very  fluid  and 
watery." 

In  the  fact  that  the  true  eruption  does  not  develop,  the  two 
extremes  of  smallpox  as  regards  gravity  meet — the  most  benignant 
form,  described  by  Sydenham,  Peter  Frank,  and  others,  as  Febris 
variolosa  sine  exanthemate — what  de  Haen  called  Variolar  sine 
variolis — and  the  so-called  Purpura  variolosa,  the  most  malignant 
form,  leading,  as  we  have  seen,  to  almost  certain  death.  Under 
this  latter  title  Curschmann  includes  those  cases  in  which  the 
process  designated  "  hemorrhagic  diathesis "  (which  I  prefer  to 
call  "acute  hemophilia")  imprints  its  frightful  stamp  upon  the 
disease  even  in  its  initial  stage,  or  during  the  eruptive  stage,  or  at 
the  close  of  the  latter. 

We  have  just  stated  that  hemorrhagic  or  purpuric  symptoms 
may  occur  not  only  in  the  stage  of  invasion  (when  they  constitute 
ordinary  Purpuric  or  Hemorrhagic  Smallpox — Purpura  variolosa) — 
but  also  at  almost  any  time  in  the  stage  of  eruption.  In  order  to 
distinguish  these  latter  cases,  as  a  matter  of  convenience,  Cursch- 
mann employs  the  term  Variola  hemorrhagica  pustulosa.  In  this 
form  of  purpuric  smallpox,  the  true  exanthem  may  become  the  seat 
of  hemorrhage  in  the  papular,  the  vesicular,  or  the  pustular  stage — 
most  commonly,  the  pocks  are  about  the  size  of  a  lentil  when  the 
bleeding  into  them  begins,  and  the  characteristic  appearance  is  seen 
first  on  the  lower  extremities. 


SMALLPOX.  93 

This  variety  of  smallpox  corresponds  exactly  to  the  "  anomalous" 
or  "irregular"  smallpox  of  1G70,  so  described  by  Sydenham,  who 
also  speaks  of  the  malady  as  "this  dangerous  black  smallpox" 
(Variolse  nigrse),  in  which  the  eruptions  "  were  more  inflamed, 
and  in  the  declension  after  their  suppuration,  frequently  looked 
black."a  Another  name  for  this  variety  isVariolae  craentae  (Bloody 
smallpox.) 

From  the  foregoing  description  we  may  compile  a  Table  of  the 
varieties  of  Smallpox,  which  will  prove  useful  for  reference.  It 
will  be  observed  that  Variola  discreta  finds  a  place  in  both  portions 
of  the  Table  :— 

I.  Variola  vera — Natural  Smallpox. 

1.  Variola  discreta,  vel  distincta. 

2.  Variola  confluens — 

(1.)    V.  conjluens  vera. 

(2.)    V.  semi-covjluens    (Syn.  :  "  Coherent  Smallpox") 

(3.)    V.  corymbosa. 

3.  Variola  maligna — 

(1.)    V.  purpurica. 
(2.)    V.  hemorrhagica. 
(3.)    V.  hemorrhagica piistulosa(Curschvaeinn).  (Syn. :  Variola 
nigra,  vel  cruente.) 

II.  Variola  modificata  vel  mitigata — Varioloid  (Variole 
modifiee) — Modified  Smallpox. 
1.    Variola  benigna — 

(1.)    V.  sine  variolis  (Syn.:  "  Variolous  Fever"). 
(2.)    V.  cornea,  vel  verrucosa  (Sy?i.:  " Hornpox,"  or  "Wart- 
pox"). 
(3.)    V.  discreta,  vel  distincta. 

In  drawing  attention  to  this  Table,  I  wish  emphatically  to  enforce 
the  view  that  all  these  various  forms  are  merely  modifications  of 
one  and  the  same  disease — namely,  Smallpox.  We  classify  these 
varieties  simply  as  a  matter  of  convenience,  and  with  Curschmann 

a  The  Entire  Works  of  Dr.  Thomas  Sydenham.  By  John  Swan,  M.D. 
London  :  F.  Newbery.     1769.     Pages  179,  et  seq. 


[■   Variola?  nigrce. 


94  SMALLPOX. 

we  should  hold  that  "none  of  these  forms  are  sharply  defined 
amidst  the  great  group  of  variolous  affections ;  but  there  is  rather 
a  gradual  transition  from  one  into  the  other,  so  that  general  out- 
lines are  to  be  associated  with  the  most  customary  designations 
rather  than  sharply  circumscribed  features."* 

Complications  and  Sequelae. 

1.  The  Skin  may  be  the  seat  of — 

(1.)  Multiple  Abscesses. 
(2.)  Phlegmonoid  Erysipelas. 

(3.)  Boils— the  "Furuncular  Diathesis"  of  Trousseau. 
(4.)  Bedsores. 

(5.)  Gangrene — very  rarely  and  only  in  the  scrotum. 
(6.)  Brownish  Discolorations  (pigment  spots)  and  Acne 
pvstulosa  on  the  face. 

2.  The  Eyes  may  be  affected  in  various  ways — 

(1.)  Conjunctivitis,  from  pustulation  or  from  irritation  by 
retained  secretions  owing  to  oedema  of  the  eyelids. 

(2.)  Abscesses  and  Sloughing  of  the  Eyelids,  caused,  it 
may  be,  by  the  presence  of  even  two  or  three 
pustules. 

(3.)  Keratitis,  or  Inflammation  of  the  Cornea  from  pustu- 
lation or  from  atrophy  leading  to  ulceration — 
"  Atrophic  Keratitis."  ._    .  r    ■ 

(4.)  Iritis,  and  Suppuration  of  the  Globe  (Panophthal- 
mitis), causing  loss  of  sight. 

(5.)  Haemorrhages  into  the  Retina  in  hemorrhagic  small- 
pox, leading  to  Blindness. 

Hebra's  experience  on  this  point  must  be  unique,  for  he  asserts 
positively  that,  of  more  than  5,000  cases  of  smallpox,  pustulation 
occurred  on  the  conjunctiva  in  only  one  per  cent.  He  holds  that 
eye-sight  is  lost  in  smallpox  only  as  a  result  of  metastatic  abscesses 
occurring  as  a  sequela.b 

a  Von  Ziemssen's  Cyclopedia  of  the  Practice  of  Medicine.     Art.  "  Smallpox." 
Vol.  II.,  page  366. 
6  Diseases  of  the  Skin.    New  Sydenham  Society.     1866.     Vol.  I.,  page  254. 


SMALLPOX.  95 

3.  The  Hearing  often  suffers.     Thus  we  may  have — 

(1.)  Chronic  Suppurative  Otitis. 

(2.)  Caries  of  the  Bones  of  the  Ear,  with  partial  or  com- 
plete deafness. 
(3.)  Suppurative  Thrombosis  of  Cerebral  Sinuses. 

4.  The  Nose  is  sometimes  the  seat  of  ulceration. 

5.  The  Tongue  may  be  enormously  swollen  (glossitis),  leading 

to  dysphagia. 

6.  (Edema  of  the  Glottis,  ushered  in  by  aphonia,  often  causes 

death  about  the  eighth  day. 

7.  Secondary  affections  of  the  Respiratory  Organs  such  as — 

(1.)  Laryngitis  (Perichondritis  laryngea),  diphtheritic  or 
catarrhal — aphonia  is  an  ominous  symptom  in  this 
complication. 

(2.)  Tracheitis. 

(3.)  Bronchitis,  nearly  always  present  in  greater  or  less 
degree. 

(4.)  Pneumonia,  usually  lobular  or  catarrhal. 

(5.)  Pleuritis,  with  purulent  effusion  from  the  outset. 

8.  Secondary  affections  of  the  Digestive  Organs  are  uncom- 

mon in  Smallpox.     They  are — 

(1.)  Diarrhoea,  which  may  cause  death,  particularly  in 

young  children. 
(2.)  Haematemesis  or  Melaena. 

9.  Secondary  affections  of  the  Circulatory  Organs  — 

(1.)  Pericarditis — very  rare  in  smallpox. 
(2.)  Haemorrhages — (a.)  cutaneous;    (/3.)  from  mucous 
membranes  ;  (7.)  from  serous  Membranes. 

10.  Secondary  affections  of  the  Renal  Organs — 

(1.)  Albuminuria. 
(2.)  Hagmaturia. 
(3.)  Acute  Nephritis. 

11.  Secondary  affections  of  the  Nervous  System — 

(1.)  Delirium,  with  or  without  Meningitis. 
(2.)  Acute  Mania  (Trousseau). 
(3.)  Various  Paralyses. 


96  SMALLPOX. 

12.  Phimosis,  from  oedema  of  the  prepuce. 

13.  Pyaemia,  or  Septicemia. 

14.  Joint  Disease,  with  painful  swellings,  effusions  of  serum 

or  pus,  inflammation  of  cartilages  and  of   bones,  may 

occur. 
Pathology. — The   morbid   anatomy   of   the  skin   and    mucous 
membranes  must  first  be  considered. 

"  Unlike  the  papule  of  measles  and  of  most  other  exanthemata," 
writes  Dr.  Hilton  Fagge,  "  the  papule  of  smallpox  depends  upon 
a  definite  change  in  the  superficial  and  middle  cells  of  the  rete 
mucosum,  which  from  the  very  commencement  of  the  morbid 
process  are  swollen  and  opaque,  and  in  their  midst  exudation 
quickly  takes  place,  so  that  by  the  end  of  two  days  the  horny 
layer  of  the  epidermis  is  raised  to  form  a  minute  conical  vesicle." 
Subsequently,  the  pustule  forms  as  a  result  of  cell  proliferation,  and 
a  central  depression — the  so-called  umbilicus — develops,  at  the 
bottom  of  which  the  opening  of  a  hair  follicle  or  sweat  gland  is, 
according  to  Curschmann,  frequently  found.  This  fact  suggests 
an  explanation  of  the  formation  of  the  umbilicus,  so  characteristic 
of  the  smallpox  pustule.  Either  of  these  structures — the  hair 
follicle  or  the  sweat  gland — may  form  a  retinaculum,  tying  down 
the  roof  of  the  vesicle  in  the  middle. 

This  explanation,  however,  is  not  always  applicable,  "  since," 
says  Dr.  Hilton  Fagge,  "  the  pock  does  not  necessarily  bear  a 
definite  relation  to  any  of  the  canals  which  traverse  the  cuticle. 
In  all  probability  a  similar  function  is  then  discharged  by  one  of 
many  other  bands  which  cross  the  upper  part  of  every  vesicle  in 
a  direction  more  or  less  vertical,  dividing  it  into  a  number  of 
separate  chambers"  (or  loculi).  "This  loculated  character  of  the 
pock  attracted  notice  long  before  its  nature  was  understood ;  it 
affords  the  reason  why  only  a  small  part  of  the  fluid  is  eva- 
cuated when  a  needle  is  introduced  into  the  roof  at  a  single 
spot.  .  .  .  Auspitz  and  Basch  showed  several  years  ago  that 
all  the  septa  in  question  are  in  reality  formed  out  of  the  original 
cells  of  the  rete  mucosum,  small  bundles  of  which  adhere  together, 
and  become  stretched  out  into  filaments  and  bands,  as  the  exuda- 


SMALLPOX.  97 

tion  accumulates  around  them.  In  this  fluid  leucocytes  are  present 
in  small  numbers  from  the  very  first ;  they  go  on  increasing,  and 
it  gradually  passes  from  transparent  serum  into  opaque  pus  ;  the 
change  is  complete  in  about  six  or  seven  days  from  the  first 
appearance  of  the  papule — that  is,  in  the  earliest  part  of  the  erup- 
tion, by  the  ninth  or  tenth  day  of  the  disease." 

The  morbid  processes  in  the  skin  are  by  no  means  confined 
solely  to  the  epidermis.  The  papillary  layer  of  the  derma  is  also 
the  seat  of  a  variolous  inflammation  which  may  have  very  impor- 
tant and  serious  consequences.  According  to  von  Barensprung,  a 
hvperaemia  extends  down  through  the  whole  thickness  of  the  skin. 
The  exudation  which  fills  the  vesicle  and  afterwards  the  pustule  is 
derived  from  these  vascular  (hyperaemic)  tissues.  Some  of  the 
papillae  are,  according  to  Curschmann,  flattened  by  pressure, 
becoming  in  consequence  permanently  atrophied.  Others,  however, 
are  infiltrated  by  leucocytes  to  such  an  extent  as  to  obliterate  their 
nutrient  blood-vessels  and  so  to  destroy  their  structure,  converting 
them  into  a  white  or  ash-gray  substance — the  diphtheritic  pock  of 
the  German  histologists.  To  prove  this,  Rindfleisch  gives  a  draw- 
ing from  an  injected  preparation,  in  which  the  affected  area  had 
failed  to  receive  any  of  the  colouring  matter  (Hilton  Fagge). 

The  liver,  kidneys,  and  spleen  undergo  important  morbid 
changes.  The  spleen  is  much  swollen,  its  pulp  soft  and  of  a  light 
red  colour,  in  those  who  die  early  in  the  disease.  It  subsequently 
resumes  its  normal  appearance  except  in  purpuric  smallpox,  when 
it  may  be  found  small,  hard,  of  a  dirty  dark  red  colour,  sometimes 
with  white  or  yellowish  follicles  (Ponfick).8,  The  liver  and  kidneys 
are  the  seat  sometimes  of  cloudy  swelling  (granular  degeneration), 
sometimes  of  acute  fatty  degeneration  resembling  that  produced 
by  poisoning  with  phosphorus.  Fatty  degeneration  is  the  more 
advanced  condition  in  which  granular  swelling  may  terminate. 
These  organs  may  be  found  normal  when  death  occurs  either  too 
soon  to  permit  of  degenerative  changes,  or  so  late  that  they  have 

a  Ueber  die    anat.     Verand.   der  innern.    Organ,   bei   hamorrh.  und   pust. 
Variol.     Berl.  klin.  Wochenschrift.     1872.     No.  42. 

H 


98  SMALLPOX. 

returned  to  their  normal  condition.     The  bile  is   generally   pale 
and  thin  in  confluent  smallpox. 

The  heart-muscle  may  undergo  degenerative  changes  like  those 
observed  in  the  liver  and  kidneys. 

In  Haemorrhagic  Smallpox,  large  or  small  haemorrhages  may  be 
found  in  nearly  all  the  viscera,  ecchymoses  in  the  serous  membranes, 
and  extravasations  of  blood  in  almost  all  the  mucous  membranes. 

Diagnosis  of  Smallpox. — The  pain  in  the  back  may  simulate 
lumbago,  which  is,  however,  apyrexial. 

The  prodromal  fever  may  be  mistaken  for  simple  continued 
fever,  which  has  no  rash. 

The  initial  rash  and  vomiting  may  be  mistaken  for  scarlatina, 
but  the  marked  sore  throat  of  this  disease  is  wanting. 

The  initial  macular  rash,  and  the  papular  stage  of  the  true  rash, 
may  be  taken  for  measles,  the  marked  coryzal  symptoms  of  which 
are  absent ;  in  measles  too  the  fever  increases  as  the  rash  comes  out, 
while  in  smallpox  it  decreases.  At  the  onset  of  a  papular  eruption 
it  is  often  difficult  to  decide  whether  the  case  is  one  of  measles 
or  smallpox.  The  following  method,  called  the  "Grisolle  sign," 
is  a  certain  means  of  diagnosis.  If  upon  stretching  an  affected 
portion  of  the  skin  the  papule  becomes  impalpable  to  the  touch, 
the  eruption  is  caused  by  measles ;  if,  on  the  contrary,  the  papule 
is  still  felt  when  the  skin  is  drawn  out,  the  eruption  is  the  result 
of  smallpox.8. 

The  pain  in  the  back  is  wanting  in  measles,  which  usually 
attacks  young  children,  whereas  smallpox  commonly  occurs  amongst 
adults. 

The  onset  of  smallpox  and  that  of  typhus  often  closely  resemble 
each  other,  but  the  fever  continues  after  the  rash  of  typhus  appears 
and  the  rash  is  macular  rather  than  papular. 

Strange  as  it  may  appear,  pustular  syphilides  have  been  con- 
founded with  smallpox  and  vice  versa  ;  but  the  clinical  history 
should  solve  the  question  without  much  trouble. 

The  differential  diagnosis  of  smallpox  and  chickenpox  (varicella) 

"■Sacramento  Medical  limes.     February,  1889.     See  Sajous'  Annual  of  the 
Univ.  Med.  Sciences.     1889.     Vol.  I.     H.-77. 


SMALLPOX.  99 

had  best  be  postponed  until  the  latter  disease  has  been  described 
(see  Chapter  XII.,  page  12o). 

The  vast  and  unsightly  swelling  of  the  face  in  confluent  smallpox 
is  very  like  erysipelas,  but  a  careful  physical  examination  would 
set  the  question  of  diagnosis  at  rest. 

Dr.  Robert  Liveinga  says  that,  of  all  diseases,  perhaps  glanders 
in  an  early  stage  is  the  one  most  likely  to  be  mistaken  for  smallpox. 
The  febrile  symptoms  are  like  those  of  smallpox,  and  the  rash 
consists  of  hard  infiltrations  in  the  skin  and  mucous  membrane, 
which  quickly  suppurate  and  form  deep  and  inflamed  ulcers.  When 
these  infiltrations  are  small  and  scattered,  and  before  ulceration  has 
begun,  the  difficulty  of  a  diagnosis  is  by  no  means  slight.  Glanders 
is  a  rare  disease  and  usually  occurs  in  grooms  and  stablemen. 
The  rash  comes  out  in  successive  crops  and  ulcerates  rapidly. 

Lastly,  in  both  recent  epidemics  of  smallpox  in  Dublin,  male 
patients  were  sent  into  Cork-street  Fever  Hospital  as  suffering 
from  smallpox,  but  on  examination  it  turned  out  that  the  suspicious 
rashes,  the  presence  of  which  caused  them  to  be  sent  to  hospital, 
were  due  to  the  fact  that  they  were  taking  cubebs  or  copaiba — the 
rashes  were  medicinal  rashes. 

In  all  cases,  account  should  be  taken  of  any  prevailing  epidemic  ; 
we  should  also  inquire  whether  the  patient  has  been  exposed  to 
any  infection  and  whether  he  has  already  suffered  from  any  of  the 
eruptive  or  continued  fevers,  which  might  be  mistaken  for  small- 
pox, or,  conversely,  smallpox  for  them. 

Prognosis. — The  mortality  from  smallpox  depends  on — (1)  the 
patient's  state  as  regards  previous  protection  by  an  attack  of  natural 
smallpox,  by  inoculation,  or  by  vaccination ;  (2)  the  virulence  of 
the  disease  itself — the  hsemorrhagic  form  being  the  most  deadly, 
next  the  purpuric  form,  then  the  confluent  form ;  (3)  the  general 
hygienic  condition,  or  otherwise,  of  the  patient's  surroundings  ; 
(4)  the  presence,  or  otherwise,  of  complications. 

Smallpox  is  most  fatal  to  unvaccinated  children  under  5  years  of 
age  and  to  unvaccinated  adults  over  30  years.     It  is  estimated 

a  Diseases  of  the  Skin.  Fifth  Edition.  London  :  Longmans,  Green  &  Co. 
1887.     Page  51. 


100  SMALLPOX. 

that  50  per  cent,  of  the  confluent  cases,  and  100  per  cent,  of  the 
malignant  cases,  perish.  The  influence  of  vaccination  for  good  is 
unquestionable — the  mortality  being  50  per  cent,  among  the  un- 
vaccinated in  general,  26  per  cent,  among  the  badly  vaccinated, 
and  only  2*3  per  cent,  among  the  efficiently  vaccinated. 

In  Sheffield,  in  the  outbreak  of  1887-88,  of  4,703  cases,  474 
proved  fatal,  or  10  per  cent.;  of  4,151  vaccinated  patients,  200 
died,  or  4-8  per  cent. ;  of  552  unvaccinated  patients,  274  died,  or 
49  6  per  cent.a 

Hemorrhagic,  or  malignant^  smallpox  may  kill  in  four,  five,  or 
six  days  from  the  earliest  symptoms.  In  confluent  smallpox,  on 
the  contrary,  the  patient  seldom  dies  before  the  eleventh  day,  and, 
in  general,  according  to  Trousseau,  the  most  fatal  epochs  are  the 
twelfth,  thirteenth,  and  fourteenth  days. 

In  the  case  of  a  disease  like  smallpox,  in  which  the  blood  is 
poisoned  and  destroyed  from  the  outset,  it  goes  without  saying 
that  defective  sanitary  surroundings — such  as  overcrowding,  want 
of  ventilation,  bad  house  drainage,  and  so  on — must  enormously 
increase  the  patient's  risk. 

Again,  the  complications  and  sequelae  of  the  disease  often  slay 
the  unfortunate  individual  who  had  escaped  from  the  perils  which 
beset  the  earlier  part  of  his  passage  through  smallpox.  (Edema  of 
the  glottis,  perichondritis  laryngea  (inflammation  of  the  cartilages 
of  the  larynx),  bronchitis  (especially  in  winter),  and  diarrhoea  may 
kill  straight  off;  while  pyaemia,  septicaemia,  and  the  furuncular 
diathesis,  may  exhaust  the  patient's  strength  after  weeks  or  even 
months  of  suffering. 

In  his  "  Medical  Report "  of  Cork-street  Fever  Hospital,  Dublin, 
for  the  year  ending  March  31,  1880,  Dr.  Reuben  J.  Harvey 
included  a  Table  showing  how  protracted  was  the  stay  in  hospital 
of  many  of  the  no n -vaccinated  patients  who  ultimately  recovered 
from  smallpox.  The  high  death-rate  among  the  unvaccinated 
cases,  fearful  as  it  is,  is  not  the  only  calamity  the  victims  of  a 
smallpox  epidemic  have  to  encounter.     In  the  year  named,  50  out 

a  Report  of  an  Epidemic  of  Smallpox  at  Sheffield,  1887-88.  By  Dr.  Barry, 
Inspector  of  the  Local  Government  Board  for  England.     London.     1889.. 


SMALLPOX.  101 

of  74  unvaccinated  patients  died  in  the  hospital.  Of  the  24  who 
recovered,  one-half  were  detained  in  hospital  for  a  period  of  from 
one  to  three  months ;  and  boils,  abscesses,  and  eye-affections 
occurred  in  these  cases  with  a  frequency  and  severity  altogether 
out  of  proportion  either  to  their  numbers  or  even  the  apparent 
severity  of  the  primary  attack. 

In  the  "  Medical  Report "  of  the  hospital  for  the  following  year 
(ending  March  31,  1881),  I  gave  a  similar  Table,  which  illustrated 
the  tediousness  of  the  recovery  of  several  non-vaccinated  patients, 
who  indeed  escaped  with  their  lives,  but  were  fated  to  pass  through 
weeks  or  months  of  suffering  before  they  were  fully  convalescent. 
In  one  case  68  days,  in  another  77  days,  and  in  a  third  106  days 
were  spent  in  hospital  by  these  victims  of  non-vaccination  small- 
pox. Even  this  was  surpassed  in  the  case  of  a  man  who  was  dis- 
charged after  a  sojourn  of  nine  months  and  nine  days.  This  unfor- 
tunate sufferer  had  as  many  as  42  large  abscesses  on  his  body  as  a 
sequel  to  the  smallpox,  but  at  length  he  happily  recovered  under 
antiseptic  treatment. 


102 


CHAPTER  X. 
The  Preventive  Treatment  of  Smallpox. 

Smallpox  communicable  ;  but  one  attack  confers  immunity  from  a  second  — 
Preventive  Measures :  1.  Isolation  ;  2.  Inoculation  ;  3.  Vaccination. — 
Inoculation  illegal.  —  History  of  Inoculation.  —  Clavelisation. — History  of 
Vaccination. — Value  of  Vaccination  in  controlling  prevalence  and  mortality  of 
Smallpox.  Marson's  views  as  to  the  use  of  Multiple  Vaccinal  Cicatrices. — 
Periodical  Revaccination. — Circumstances  which  conduce  to  success  of 
Vaccination. — Jenner's  "  Golden  Rule." — Bovine  and  Humanised  Lymph. — 
Performance  of  Vaccination. — Bryce's  Test. — Vaccina  :  its  local  and  con- 
stitutional symptoms. — Vaccino-stphilis. 

This  subject  of  the  Treatment  of  Smallpox  naturally  falls  under 
the  two  headings — Preventive  Treatment,  or  Prophylaxis,  and 
Curative  Treatment. 

Preventive  Treatment — The  principles  of  the  Prophylaxis  of 
Smallpox  are  based  upon  two  facts  in  the  natural  history  of  the 
disease — namely  (1).  Smallpox  is  eminently  communicable.  (2). 
One  attack  usually  protects  an  individual  from  a  second  attack — 
confers  immunity  upon  him. 

The  preventive  measures  which  call  for  remark  are — (1).  Isola- 
tion of  the  Sick ;  (2).  Inoculation ;   (3).  Vaccination. 

1.  Of  these  topics,  the  first  has  already  been  discussed  in  the 
chapter  on  the  Preventive  Treatment  of  the  Acute  Specific  Fevers 
(see  pages  30  et  seq.).  It  will  be  sufficient,  therefore,  to  repeat 
that  isolation  consists  in  the  removal  of  sick  to  suitable  epidemic 
hospitals,  the  providing  of  refuges  for  the  inhabitants  of  infected 
tenement  houses  or  other  dwellings,  efficient  disinfection,  and  the 
establishment  of  convalescent  homes. 

2.  As  regards  inoculation,  the  intention  was  to  engraft  a  mild 
form  of  smallpox  on  a  healthy  individual,  whose  receptivity  or 
susceptibility  might  be  supposed  to  be  slight  or  low  in  consequence 
of  his  existing  good  health.  The  disadvantages  of  this  procedure 
was  that  it  gave  smallpox  to  many  who  would  otherwise  have, 
perhaps,  escaped  the  disease  altogether,  while  it  was  impossible  to 
guarantee  that  the  resulting  attack  of  smallpox  would  be  mild. 


SMALLPOX. 


103 


In  1840  an  Act  of  Parliament  was  passed  rendering  smallpox 
inoculation  unlawful  in  England  (3  and  4  Vict.,  cap.  29). 

Inoculation  was  declared  to  be  illegal  in  Ireland  by  the  fourth 
section  of  the  "Vaccination  Amendment  (Ireland)  Act"  of  1868 
(31  &  32  Vict.,  cap.  87). 

The  operation  had  been  practised  from  time  immemorial  in 
China  and  Persia.  The  Chinese  plan  of  giving  smallpox  to  per- 
sons in  health  consisted  in  inserting  into  the  nostrils  tents  of 
charpie  covered  with  the  dried  crusts  of  the  variolous  eruption.  They 
called  the  procedure  "sowing  the  smallpox."  From  China  and 
Persia  inoculation  or  "  engrafting "  was  introduced  into  Georgia, 
Circassia,  Turkey,  and  Greece.  In  1717,  a  very  clever  English- 
woman, by  name  Lady  Mary  Wortley  Montague,  wife  of  the  British 
Ambassador  at  the  Ottoman  Court,  wrote  home  glowing  accounts 
of  the  marvellous  results  of  inoculation  as  practised  at  Adria- 
nople,  amongst  other  persons,  upon  her  own  son,  a  boy  of  six  years 
of  age.  Her  influence  led  to  the  open  adoption  of  the  procedure 
in  England  in  April,  1721,  and  two  years  later,  in  1723,  Dr.  Bryan 
Robinson,  sometime  President  of  the  King  and  Queen's  College  of 
Physicians,  first  performed  the  operation  in  Ireland.  Many  years 
elapsed  before  it  obtained  a  footing  in  France,  where  at  first  it 
had  been  rigorously  prohibited  by  law  ;  but  in  1756  the  children 
of  the  Duke  of  Orleans  were  inoculated,  and  in  1758  the  practice 
was  introduced  into  most  of  the  large  towns. 

A  favourite  analogous  procedure,  practised  since  the  last  cen- 
tury by  Continental  veterinary  surgeons  and  farmers,  was  called 
clavelisation — a  term  derived  from  clavelee,  the  French  name  for 
smallpox  of  sheep  ( Variolas  ovivce),  a  disease  popularly  known  in 
England  as  "  tag-sore,"  or  "  sheep-rot ;"  in  Italy  as  "  vaccuolo." 

The  object  of  clavelisation  was  by  repeated  inoculations  to 
attenuate  the  virus  of  sheep-pox.  And  exactly  in  the  same  way 
it  was  sought,  by  employing  virus  from  a  discrete  case  of  smallpox 
which  had  been  modified  by  antecedent  inoculation,  to  communi- 
cate a  very  mild  variola. 

The  operation  consisted  in  raising  the  epidermis  by  means  of  a 
lancet  charged  with  such  an  attenuated  virus  or  lymph.     A  mere 


]  04  SMALLPOX. 

prick  was  sufficient.  The  resulting  symptoms  were,  first  local, 
then  constitutional.  Thus,  on  the  second  day  after  inoculation,  a 
small  red  pimple  appeared  at  the  site  of  puncture ;  by  the  fifth  day 
this  had  become  a  conical  vesicle  (sometimes  umbilicated)  ;  on  the 
seventh  day,  the  vesicle  had  developed  into  a  pustule,  surrounded 
by  a  slightly  red  inflammatory  areola,  which  gradually  increased 
np  to  the  ninth  or  tenth  day,  when  a  ring  of  secondary  small 
pustules,  true  satellites  of  the  first,  formed  upon  the  inflammatory 
areola.  This  pustule  of  inoculation  resembled  a  kind  of  large 
pock  which  is  sometimes  found  in  natural  smallpox,  and  to  which 
Van  Swieten,  of  Vienna,  gave  the  name  of  Meisterpocken,  master- 
pock,  or  what  Trousseau  called  le  maitre  bouton. 

On  the  ninth  or  tenth  day  after  inoculation,  the  constitutional 
symptoms  used  to  make  their  appearance.  They  were,  in  a  word, 
all  the  primary  or  prodromal  symptoms  of  smallpox.  Finally, 
about  the  eleventh,  twelfth,  or  thirteenth  day,  the  specific  eruption 
was  seen — in  general  but  slightly  confluent,  following  the  course 
of  ordinary  or  sometimes  that  of  modified  smallpox. 

I  have  given  Trousseau's  account  of  the  phenomena  attending 
inoculation  at  this  length,  because  they  are  exactly  analogous  to 
the  features  presented  after  successful  vaccination. 

3.  Vaccination  (Germ.  Kuhpockenimpfung). — About  the  middle 
of  the  eighteenth  century  the  opinion  gained  ground  in  England 
that  inoculation  with  cowpox  lymph  protected  from  smallpox. 
As  Dr.  E.  Crookshank,  in  his  elaborate  "  History  and  Pathology  of 
Vaccination,"  says  : — "  In  some  parts  of  the  country  a  belief  existed 
among  those  who  had  the  care  of  cattle  that  a  disease  of  cows,  which 
they  called  '  cowpox,'  when  communicated  to  the  milkers,  afforded 
them  protection  from  smallpox."  It  is  necessary  to  explain  that 
various  domestic  animals  are  liable  to  a  disease  which  is  practi- 
cally smallpox.  Thus,  a  variety  of  the  grease  (Ft.  eaux  aux  jambes) 
of  horses — in  which  an  eruption  appears  usually  on  the  foot-joints — 
is  properly  called  "  Variola?  equina."  The  "  tag-sore  "  (Fr.  clavele'e) 
of  sheep  is  "  Variola?  ovince  ;  "  and  the  well-known  ''  cowpox,"  in 
which  the  eruption  is  almost  exclusively  observed  upon  the  udder 
and   teats    of   the   cow   is   technically   called  "  Variolat   vaccina?" 


SMALLPOX.  105 

Fr.  picote),  or,  shortly,  "Vaccina"  (the  form  "  Vaccinia"  being 
etymologically  incorrect). 

At  a  time  when  the  majority  of  the  people  were  deeply  pitted 
with  smallpox,  the  immunity  enjoyed  by  the  comely  milkmaids  of 
Gloucestershire  and  Devonshire  from  the  unsightly  scars  left  by 
the  disease  could  not  fail  to  attract  attention.  It  was  noticed  that 
the  dairymaids  and  farm -labourers  were  subject  to  an  attack  of 
sores  on  their  hands,  which  seemed  to  arise  from  contact  with 
pustules  on  the  udders  of  milch  cows.  Those  who  suffered  from 
this  apparently  local  malady  of  sore-hands  were  observed  to  escape 
smallpox.  At  length,  in  1774,  Benjamin  Jesty,  a  Gloucestershire 
farmer,  who,  however,  had  been  born  at  Yetminster,  in  Dorsetshire, 
became  so  convinced  of  the  protective  efficacy  of  cowpox  against 
smallpox  that  he  inoculated  his  wife  and  two  sons  with  cowpox — 
thus  performing  vaccination  for  the  first  time,  and  anticipating 
Edward  Jenner  by  no  fewer  than  twenty-two  years.a  On  May  14, 
1796,  Jenner  vaccinated  a  peasant  lad,  whom  he  failed  to  inoculate 
with  smallpox  two  months  afterwards.  The  crucial  test  was  in  this 
way  applied  to  the  efficacy  of  vaccination  as  a  preventive  measure. 

It  would  be  foreign  to  my  present  purpose  to  linger  over  the 
history  of  vaccination ;  nor  is  it  necessary  at  this  time  of  day  to 
take  much  trouble  to  refute  the  views  of  the  fanatical  "anti- 
vaccination"  party.  Before  the  introduction  of  vaccination,  the 
annual  mortality  from  smallpox  in  England  and  Wales  alone  was 
at  the  rate  of  3,000  deaths  in  every  million  of  the  population — 
this,  according  to  the  Census  of  1891,  would  correspond  to  a  loss 
of  some  87,000  lives  per  annum — the  population  of  England  and 
Wales  being  29,081,047  in  April  of  this  year.  What  are  the 
actual  facts  ?  In  1890,  smallpox  caused  only  15  deaths  in  England  ; 
and  the  average  annual  number  of  deaths  from  this  disease  in  the 
ten  years  1881-90  inclusive,  was  1,227*8 — that  is,  one-seventieth 
part  only  of  the  death-rate  of  pre-vaccination  times. 

But  vaccination  has  not  only  diminished  the  number  of  cases  of 
and  deaths  from  smallpox — it  is  also  found  to  influence  the  death- 
rate  among  those  attacked  to  a  very  remarkable  extent.  In  Sheffield, 
a  See  The  Lancet,  September  13,  18C2.     Page  291. 


106 


SMALLPOX. 


in  the  outbreak  of  1887-88  already  referred  to,  of  4,151  vaccinated 
patients,  200  died,  or  4-8  per  cent. ;  of  552  unvaccinated  patients, 
274  died,  or  49*6  per  cent. 

The  following  Tables  are  taken  from  a  Report  on  the  Epidemic 
of  1871-72,  as  observed  in  Cork-street  Fever  Hospital,  Dublin,  by 
Dr.  T.  W.  Grimshaw,  now  Registrar-General  for  Ireland  and  Con- 
sulting Physician  to  the  Hospital*  : — 


Hospitals 

Cork-street 

Haidwicke 

Cork 

London  Smallpox 

Hampstead  (London) 

Homerton 


Table  II. 

Mortality  per  Cent. 
Vaccinated     Unvaccinated     General 


10-8 

71-8 

21-6 

11-2 

78-57 

20-0 

5-5 

58-0 

22-5 

14-9 

66-2 

18-8 

11-4 

51-2 

19-36 

5-9 

37-7 

16-3 

Table  III. 


— 

Discrete 

Confluent 

Malignant 

Total 

Total 

Died 

s  s 

Total 

Died 

fa 

Total 

Died 

Si 

Total 

Died 

^  >■ 

Vaccinated   - 
Unvaccinated 

443 

17 

1 
6 

0-2 
35-1 

143 

94 

46 
67 

32-3 

712 

25 
24 

18 

24 

71-8 
100-0 

611 
135 

65 

97 

10-8 
71-8 

Total     - 

460 

7 

1-6 

237 

113 

47-6 

49 

42 

85-7 

746 

162 

21-6 

Percent,  vac- 
cinated   in 
each  class 

(         96-3 

60-4 

51-9 

81-8 

Of  the  vaccinated  cases  in  the   discrete  variety,  the  mortality 

a  See  Manual  of  Public  Health  for  Ireland.  Dublin  :  Fannin  &  Co.  1875. 
Pages  172  &  173.  Also  Special  Report  on  the  Smallpox  Epidemic,  1871-73,  as 
observed  in  Cork-street  Fever  Hospital,  Dublin.  By  T.  W.  Grimshaw,  M.D. 
Being  an  Appendix  to  the  Medical  Report  of  that  Hospital  for  the  year  ending 
March  31,  1873.    Dublin  :  John  Falconer.     1875. 


SMALLPOX.  107 

was  practically  nothing  (0-2  per  cent.),  only  one  patient  having 
died.  In  that  case  the  patient  had  inflammation  of  the  lungs, 
probably  quite  independent  of  the  smallpox.  Of  the  unvaccinated 
patients,  however,  in  this  class,  35'1  per  cent.  died.  In  the  con 
fluent  cases  the  mortality  among  the  vaccinated  patients  was  323 
per  cent.,  while  among  the  unvaccinated  it  was  as  high  as  7 i*2 
per  cent.  In  the  malignant  or  purpuric  variety,  the  mortality 
among  the  vaccinated  patients  was  71*8  per  cent.,  or  about  the 
same  as  among  the  unvaccinated  confluent  cases,  while  in  this 
variety  not  one  unvaccinated  case  recovered.  It  may  be  merely  a 
coincidence  of  percentage  mortality ;  but  it  is  a  remarkable  fact 
that  in  the  cases  under  consideration  vaccination  reduced  the  mor- 
tality of  confluent  cases  to  that  of  discrete  unvaccinated  cases,  and 
that  of  malignant  to  that  of  confluent  unvaccinated  cases.  The 
proportion  of  vaccinated  to  unvaccinated  cases  in  each  variety  is 
considerably  greater,  except  in  the  malignant  form,  where  the 
proportions  are  nearly  equal.  The  difference  is  most  remarkable 
in  the  discrete  variety,  where  the  number  of  unvaccinated  cases  is 
very  small — in  other  words,  vaccination  prevented  a  large  number 
of  these  cases  from  being  confluent. 

In  my  "  Medical  Report  of  the  Fever  Hospital  and  House  of 
Recovery,  Cork-street,  Dublin,"  for  the  year  ending  March  31, 
1879,  I  give  an  account  of  the  still  more  terrible  epidemic  of 
1876-1879,  proceeding  on  very  much  the  same  lines  as  Dr.  Grim- 
shaw's  Report.  The  number  of  cases  with  which  the  Report  deals 
is  so  large — namely,  1,804  from  April  1,  1876,  to  March  31, 
1879 — that  the  results  may  be  fairly  considered  conclusive  as  to 
the  modifying  influence  of  vaccination  over  (1)  the  type  of  the 
disease,  and  (2)  its  fatality.  Of  1,003  patients  who  suffered  from 
discrete  smallpox,  943  were  vaccinated,  and  only  60  were  unvac- 
cinated— the  percentage  of  those  vaccinated  being  94'0.  There 
were  10  deaths — the  mortality  being  one  per  cent.  Among  these 
10  deaths  was  that  of  an  infant  of  9  months,  who  was  not  vacci- 
na'ed.  Seven  patients  succumbed  to  the  complications  of  discrete 
smallpox,  dying  in  or  after,  not  of  this  disease. 

Of  604  patients  suffering  from  confluent  smallpox,  377   were 


108  SMALLPOX. 

vaccinated  and  227  were  uuvaccinated — that  is,  62*4  only  of  every 
100  patients  were  vaccinated.  There  were  243  deaths,  the  rate  of 
mortality  being  40'2  per  cent.  But  of  the  vaccinated  only  22  per 
cent,  died,  compared  with  70*5  per  cent,  of  the  unvaccinated. 

Of  197  malignant  cases,  110  were  vaccinated,  or  55*8  per  cent., 
and  77  were  unvaccinated.  The  deaths  numbered  151,  the  mor- 
tality being  76*6  per  cent.  Of  the  vaccinated  67-2  per  cent,  died, 
but  of  the  unvaccinated  88-5  died. 

Of  the  1,804  patients  in  all,  who  were  admitted,  1,430,  or  79-2 
per  cent.,  were  vaccinated,  and  374  were  not  vaccinated.  There 
were  404  deaths,  or  a  mortality  of  22-3  per  cent.  Among  the 
vaccinated  166  deaths  occurred,  the  mortality  falling  to  11*6  per 
cent.  Among  the  unvaccinated  238  deaths  occurred,  the  mortality 
rising  to  63-6  per  cent. 

In  very  few  instances,  indeed,  had  the  patients  been  revacci- 
nated,  probably  not  in  more  than  5  of  the  whole  1,804  cases. 

Many  years  ago  Mr.  Marson,  of  the  Smallpox  Hospital,  London, 
showed  as  a  result  of  his  examination  of  5,000  cases,  between 
1836  and  1855,  that  the  number  of  vaccinal  cicatrices  seem  to 
influence  the  mortality  from  smallpox.  The  death-rate  among 
patients  having  only  one  cicatrix  was  7*73  per  cent. ;  that  among 
those  who  had  two  cicatrices  was  4*7 ;  that  in  the  presence  of 
three  cicatrices  was  1*95,  and  that  with  four  or  more  cicatrices  was 
only  0*55  per  cent. 

There  can  be  no  doubt  that  the  protective  efficacy  of  vaccination 
wears  out  gradually  with  the  lapse  of  time.  Periodical  revacci- 
nation  every  seven  or  ten  years  is,  therefore,  necessary  if  small- 
pox is  to  be  completely  prevented,  any  case  where  revaccination 
at  stated  intervals  has  failed  being  always  of  a  most  peculiar  nature. 

That  vaccination  has  in  rare  instances  done  harm  cannot  be  dis- 
puted. Unsuitable  subjects  have  been  vaccinated,  or  the  lymph 
has  been  taken  .from  improper  sources ; a  but  such  mishaps  afford 
no  valid  argument  against  the  practice  of  vaccination,  however 
much  they  may  lead  us  to  call  in  question  the  skill  and  care  of  the 
operator  in  each  untoward  case. 

a  Grimshaw.     Loc.  cit. 


SMALLPOX.  109 

The  circumstances  which    conduce   to   the   success  of  the 
operation  are  briefly  the  following  : — 

1.  The  subject   to  be  vaccinated  should   be   healthy.     Special 

provision  is  made  in  the  Vaccination  Act  for  postponing  the 
operation  if  the  individual  is  not  quite  well.  The  presence 
of  skin  diseases  and  the  propinquity  of  scarlet  fever  or 
erysipelas  forbid  the  operation. 
The  periods  of  teething  and  of  weaning  should  be  avoided  for  the 
performance  of  vaccination. 

2.  The  vaccinifer  should   also  be   healthy,   vaccinated   for  the 

first  time,  and,  above  all,  free  from  any  syphilitic  taint. 
The  best  age  is  from  5  months  to  over  a  year  old ;  but 
vaccination  may  be,  and  — in  epidemic  times — should  be, 
performed  much  earlier.  In  1878,  smallpox  raging  at  the 
time,  I  vaccinated  one  of  my  own  children  at  the  age  of 
three  weeks  successfully  and  without  any  untoward  result. 

3.  The  lymph  should   be  taken  between  the  fifth  and  eighth 

days.  As  a  French  medical  poet,  Casimir  Delavigne  by 
name,  quoted  by  Trousseau,  sings  :— 

"  Puisez  le  germe  heureux  dans  sa  fralcheur  premiere 
Quand  le  soleil  cinq  fois  a  fourni  sa  carriere." 

"  Draw  forth  the  auspicious  germ  in  its  first  freshness, 
When  the  sun  has  five  times  completed  his  course." 

The  eighth  day,  inclusive,  is  generally  selected  in  the  United 
Kingdom  as  that  of  inspection. 

4.  The  incisions,  or  scarifications,  should  not  penetrate  to  the 

subcutaneous  areolar  tissue.  They  should  be  made  with  a 
scrupulously  clean  instrument. 

5.  Bleeding  should  be  avoided    as  much  as   possible,  lest   the 

lymph  should  be  washed  away  from  the  site  of  inoculation. 
Blood  should  not  be  drawn  when  piercing  the  vesicle  to 
obtain  the  lymph. 

6.  Jenner's  "golden  rule"  should  always  be  observed,  and  that 

is — not  to  use  lymph  from  a  vesicle  which  has  already  showed 
the  "  areola,"  or  inflammatory  ring  which  forms  around  the 
vaccine  vesicle  at  the  beginning  of  the  second  week. 


110  SMALLPOX. 

7.  A  thin,  serous,  readily-flowing  lymph  should  not  be  used. 
Good  lymph  is  perfectly  limpid  and  viscid  or  sticky. 

Whenever  practicable,  the  lymph,  which  may  be  bovine  or 
humanised,a  should  be  carried  directly  from  arm  to  arm.  This, 
however,  is  often  impossible,  and  so  the  lymph  must  be  preserved 
for  future  use.  The  old-fashioned  method  was  to  allow  the  lymph 
to  dry  in  a  thin  film  on  flat  ivory  or  bone  points.  A  much  better 
plan  is  to  preserve  the  lymph  in  hermetically  sealed  capillary 
glass  tubes.  Miiller,  of  Berlin,  usually  mixes  the  lymph  carefully 
with  two  parts  of  glycerine  and  two  parts  of  distilled  water  (by 
means  of  a  small  brush)  in  a  watch  glass,  and  preserves  this 
diluted  vaccine  lymph  in  air-tight  capillary  tubes.  The  activity 
of  the  lymph  is  not  impaired  by  this  procedure,  and  the  precious 
virus  is  economised. 

Vaccination  is  generally  done  upon  the  outside  of  the  left  arm — 
in  girls,  at  the  place  where  the  scars  will  be  as  far  as  possible 
hidden  by  the  future  evening  dress.  At  least  two  sets  of  minute 
punctures  or  scarifications  are  made  with  a  vaccinating  needle  or 
lancet,  moistened  or  "armed"  with  the  lymph,  at  each  side  of  the 
deltoid  muscle  as  it  passes  down  to  its  insertion  on  the  outer  aspect 
of  the  humerus.  A  little  of  the  lymph  should  afterwards  be  rubbed 
into  the  punctures. 

Various  instruments  for  vaccination  have  been  designed,  one  of 
the  neatest  and  best  being  Rose's  "  vaccinator."  This  ingenious 
little  instrument  consists  of  a  lancet-blade  at  one  end,  and  a  series 
of  prodding  or  "tattooing"  needles,  arranged  like  the  five  of  dice, 
at  the  other.  A  rotatory  movement  projects  the  needles  from  the 
case,  causing  them  to  puncture  the  skin,  and  the  lymph  can  then 
be  rubbed  in  from  the  surface  of  the  lancet. 

According  to  Hebra,  the  most  satisfactory  instrument  is  a 
lancet  having  one  surface  convex,  the  other  hollowed  and  pre- 
senting a  groove  to  which  a  drop  of  the  lymph  adheres. 

Another  instrument,  called  by  the  Germans  Impffeder,  or 
Vaccine-pen,  resembles  a  drawing  pen,  and  consists  of  two  parallel 
limbs  with  cutting  extremities,  between  which  the  lymph  is  taken 

a  That  is,  derived  from  the  heifer  or  from  a  human  being  already  vaccinated. 


SMALLPOX.  Ill 

up  by  capillary  attraction.  In  employing  this  instrument  the 
vaccine  matter  is  introduced  beneath  the  cuticle  by  a  horizontal 
or  vertical  incision  (Hebra). 

Sir  Thomas  Watson  a  says  that  a  very  ingenious  test,  free  from 
all  ambiguity,  by  which  we  determine  whether  the  cowpox  is 
runniug  its  proper  course  or  not,  was  devised  by  Mr.  Bryce — hence 
called  "Bryce's  test."  His  plan  was  this.  He  vaccinated  the 
other  arm,  or  some  other  part  of  the  body  four  or  five  days  after 
the  first  vaccination.  If  the  system  had  been  properly  affected 
by  the  first  operation,  the  inflammation  of  the  second  vesicle  would 
proceed  so  much  more  rapidly  than  usual  that  it  would  be  at  its 
height  and  would  decline  and  disappear  as  early  as  that  of  the  first : 
only  the  vesicle  and  its  areola  would  be  smaller.  One  of  the 
earliest  disciples  of  Dr.  Jenner,  Mr.  Hicks,  used  in  a  doubtful  case 
to  repeat  vaccination  in  a  few  days  after  the  first  operation,  and 
he  remarked  that  the  second  vesicle  made  "  immense  strides  to 
overtake  the  first." 

Vaccina. — The  symptoms  of  this  affection  are  first  local  and  then 
constitutional — the  latter  in  most  cases  being  very  slightly  marked. 
On  the  third  day  (inclusive)  a  patch  of  redness  at  the  site  of  vacci- 
nation appears  and  rapidly  develops  into  a  papule  or  pimple,  which 
in  its  turn,  about  the  fifth  day,  becomes  surmounted  with  a  pearly 
vesicle,  multi-locular,  oval  or  circular  in  outline,  with  raised  margin 
and  depressed  centre.  This  vesicle  enlarges,  while  its  contents 
also  increase — remaining,  however,  clear  as  crystal — until  the 
eighth  day,  when  it  attains  its  perfect  growth.  An  inflammatory 
red  zone,  called  the  "  areola,"  now  develops,  beginning  round  the 
base  of  the  vesicle  and  thence  spreading  out,  perhaps  to  a  dis- 
tance of  two  or  three  inches.  After  the  tenth  day  the  areola 
fades,  and  the  vesicle  begins  to  shrink  and  dry  up  in  the  centre. 
The  contained  lymph^  becomes  opaque  and  thickens.  By  the  four- 
teenth or  fifteenth  day  a  hard,  dry,  brown  scab  forms,  which  finally 
separates  and  falls  off  about  the  twenty-first  day.  A  circular, 
slightly  depressed,  foveate  (or  pitted)  cicatrix  remains,  which — 
except  in  rare  instances — is  permanent  through  after-life. 
a  Loc,  cit.,  page  792. 


112  SMALLPOX. 

During  the  earlier  stages,  the  vaccine  vesicles  should  be  relieved 
from  any  pressure  or  friction,  which  might  increase  inflammatory 
action.  In  all  cases,  the  vaccinated  person  should  be  seen  on  the 
eighth  day — the  day  week — from  the  operation,  when  a  certificate 
of  successful  vaccination  may  be  given  if  the  vesicle  is  well-formed 
and  running  a  natural  course. 

The  constitutional  symptoms  are — slight  pyrexia  from  the  fourth 
day,  becoming  more  marked  from  the  eighth  to  the  tenth  days ; 
often  derangement  of  the  stomach  and  bowels  during  the  stage  of 
areola,  with  restlessness.  The  axillary  glands  may  also  swell,  and 
rashes  may  show  upon  the  skin — either  a  blush  (  Vaccinal  Roseola), 
or  a  crop  of  papules  (  Vaccinal  Lichen),  or  a  vesicular  rash  (  Vaccinal 
Herpes).  In  normal  cases  all  these  symptoms  subside  in  a  few 
days,  or  they  may  fail  to  appear  at  all. 

Vaccino-Syphilis. — The  inoculation  of  the  syphilitic  virus  along 
with  vaccine  at  the  time  of  vaccination  is,  in  the  words  of  Dr.  C. 
E.  Shelly,  the  writer  on  the  subject  in  Fowler's  Dictionary  of 
Practical  Medicine,  "  the  most  lamentable  accident  by  which  care- 
lessness or  misfortune  can  prejudice  the  performance  of  vaccina- 
tion." Since  the  incubation  period  of  syphilis — namely,  from  three 
to  five  weeks — is  much  longer  than  that  of  vaccina,  the  latter 
affection  usually  runs  its  course  before  the  local  inflammation  which 
constitutes  a  specific  chancre  begins.  This  is  attended  by  the  usual 
glandular  enlargement  {axillary  bubo)  and  is  followed  in  due  course 
by  the  recognised  secondary  symptoms  of  constitutional  syphilitic 
infection.  If  the  precautions  in  the  performance  of  vaccination 
described  in  the  foregoing  pages  are  strictly  carried  out,  it  is  simply 
impossible  that  the  disgraceful  accident  of  simultaneously  inoculat- 
ing syphilis  can  occur. 


113 


CHAPTER  XL 
The  Curative  Treatment  of  Smallpox. 

No  specific  for  Smallpox — two  great  Principles  of  Treatment  :  (1)  to 
guide  the  essential  disorder,  (2)  to  combat  secondary  affections. — "Hot  Regi- 
men  "  treatment  of  olden  times. — Thomas  Sydenham's  "Cooling  Regimen." — 
Treatment  of  Discrete,  Confluent,  and  Hsemorrhagic  Smallpox. —Two  dangers 
in  Confluent  Smallpox  :  general  blood-poisoning,  and  exhaustion. — Antiseptic 
Treatment. — Prevention  of  "Pitting." — Dr.  Stokes's  views. — Three  Indica- 
tions for  Treatment  :  (1)  to  exclude  air,  (2)  to  keep  the  surface  in  a  perma- 
nently moist  state.  (3)  to  lessen  the  local  irritation. — Hebra's  Treatment  by 
the  Warm  Bath. — Dr.  Stokes's  account  of  this  method. — Hebra's  apparatus  for 
the  Continual  Bath. — Treatment  of  Affections  of  the  Skin  in  Smallpox,  and  of 
the  various  Local  Affections. — Turpentine  and  Ergot  in  Haemorrhage. — Trans- 
fusion of  Blood. 

The  superscription  of  this  Chapter  is  in  one  sense  somewhat  mis- 
leading. No  physician  has  ever  yet  cured  a  case  of  smallpox.  No 
specific  for  the  disease  or  for  its  many  complications  and  sequela? 
has  as  yet  been  discovei*ed.  Accordingly  we  must  be  content  to  set 
before  us  two  great  principles  of  treatment — first,  to  guide  the 
essential  disorder  to  a  favourable  termination  ;  and,  in  the  next 
place,  to  combat  secondary  affections  as  they  arise. 

There  can  be  no  doubt  that  the  mortality  from  smallpox  was 
enormously  increased  during  the  Middle  Ages  by  mistaken  and 
ignorant  treatment.  The  old  physicians  did  all  they  could  to  pro- 
tect the  patient  from  cold  and  to  promote  a  copious  eruption, 
adopting  the  vulgar  maxim  that  i'  it  was  better  out  than  in."  In 
the  fourteenth  century  flourished  John  of  Gaddesden,  author  of  a 
curious  book  entitled  Rosa  Anglica,  court  physician  of  the  day,  but 
"  a  very  sad  knave,"  as  Sir  Thomas  Watson  calls  him.  This  repre- 
sentative physician  of  the  Age  not  only  put  the  unhappy  smallpox 
patient  on  a  "hot  regimen,"  administering  wine  and  cordials,  piling 
on  bed-clothes,  and  jealously  excluding  every  breath  of  fresh  air 
from  the  sick-room,  but  surrounded  the  half -suffocated  victim  with 
red  curtains,  red  walls,  and  red  furniture  of  all  kinds — for  in  this 
colour  there  was,  he  pretended,  a  peculiar  virtue. 

I 


1 14  SMALLPOX. 

To  the  celebrated  Thomas  Sydenham,  who  lived  in  the  seven- 
teenth century,  belongs  the  credit  of  substituting  for  this  barbarous 
and  disastrous  system  of  treatment  the  opposite  or  "cooling 
regimen"  in  smallpox,  and  this  practice  is  pursued  to  the  present 
day  with  the  happiest  results. 

Premising  that  the  reader  has  mastered  the  general  principles  of 
treatment  of  the  specific  fevers  laid  down  in  Chapters  IV.  and  V., 
I  will  proceed  to  consider  what  further  measures  should  be  adopted 
in  the  case  of  Smallpox  under  its  three  chief  forms — Discrete,  Con- 
fluent, and  Malignant  or  Hemorrhagic. 

Discrete. — The  patient,  having  been  placed  in  bed  in  a  large, 
airy  and  well- ventilated,  but  warm  room,  should  be  carefully  and 
skilfully  nursed :  his  hair  should  be  cut  close,  his  hands  and  face 
should  be  washed  daily,  or  twice  a  day,  with  warm  carbolised 
water,  from  1  to  2  per  cent,  in  strength,  or  with  a  weak  solution  of 
corrosive  sublimate  (1-2000).  Warm  baths  are  very  useful  and 
refreshing.  The  water  may,  with  advantage,  be  tinged  with  per- 
manganate of  potassium  solution,  bearing  in  mind,  however,  that 
this  is  decolourised  at  once  and  rendered  inert  by  soap. 

Confluent  Smallpox. — The  pain  in  the  back  may  be  relieved  by 
dry  cupping,  or  by  the  application  of  an  India-rubber  bag  filled 
with  hot  water,  or  by  a  hypodermic  injection  of  ergotin.  An  ice- 
bag  applied  to  the  head  will  often  control  headache.  In  all  the 
severer  forms  of  the  disease,  the  patient  should  not  be  allowed  to 
assume  the  upright  position  for  fear  of  syncope,  which  is  especially 
likely  to  come  on  after  a  free  evacuation  of  the  bowels. 

In  confluent  smallpox  the  patient  is  beset  by  two  dangers  in  par- 
ticular— general  blood-poisoning  from  the  intense  and  widespread 
suppuration,  and  exhaustion  from  pain,  sleeplessness,  delirium  and 
long-continued  fever. 

To  check  the  development  of  a  copious  eruption  antiseptics  have 
been  recommended  and  tried,  but  with  no  striking  or  even  satis- 
factory results.  One  of  the  best  and  fullest  accounts  of  the  anti- 
septic treatment  of  smallpox  will  be  found  in  a  paper  by  my 
colleague,  Dr.  Arthur  Wynne  Foot,  Physician  to  the  Meath  Hospital, 
in  Vol.  LIII.  of  The  Dublin  Journal  of  Medical  Science,  pages  242, 


SMALLPOX.  115 

ct  seq.  The  way  in  which  he  endeavoured  to  carry  out  this  treatment 
in  the  wards  of  the  Meatli  Hospital  during  the  epidemic  of  1871-72 
was  by  giving  carbolic  acid  internally  in  the  shape  of  the  sulpho- 
carbolate  of  sodium  (in  doses  of  from  7  grains  occasionally  to  60 
grains  in  water  every  third  hour),  or — when  more  suitable — the 
sulpho-carbolate  of  iron  ;  by  giving  the  sulphurous  acid  of  the  British 
Pharmacopoeia,  diluted  with  water — one  drachm  in  a  wineglassful 
or  two  of  iced  water — as  the  usual  drink ;  by  spraying  the  larynx 
with  it,  and  washing  the  nares  and  upper  surface  of  the  palate  with 
solutions  of  sulphurous  or  of  carbolic  acid ;  by  keeping  carbolised 
oil  to  the  face;  by  washing  the  body  with  solutions  of  sulphurous 
acid  or  of  vinegar  and  water ;  by  throwing  pure  sulphurous  acid 
about  the  bed  and  bed-clothes  of  the  patient;  and  by  burning 
sulphur  in  the  sick-room. 

My  own  experience  is  that  in  quinine  and  in  perchloride  of 
iron  we  possess  the  two  most  valuable  antiseptics  for  internal  use 
so  far  as  smallpox  is  concerned.  Quinine  may  be  given  in  5-grain 
doses  thrice  daily  or  oftener.  This  dose  7nay  be  administered  in 
water  with  just  enough  dilute  hydrochloric  acid  to  dissolve  it,  or 

with  dilute  hydrobromic  acid  and  water,  or  mixed  with  fresh  milk 

when  three  grains  of  powdered  camphor  may  with  advantage  be 
added  to  each  dose.  Either  the  tincture  or  the  solution  of  ferric 
chloride  may  be  given  in  20  to  30  minim  doses,  with  glycerine 
(3  ss.)  and  water  (3  vii.),  and  perhaps  a  few  minims  of  liquor 
strychninas  hydrochloratis. 

If  we  possessed  any  certain  means  of  checking  the  development 
of  a  confluent  rash  in  smallpox,  much  distress  and  even  danger  to 
life  in  the  first  instance,  and  later  on  permanent  disfigurement 
would  be  avoided.  In  a  characteristic  paper  entitled  "  Some  Notes 
on  the  Treatment  of  Smallpox,"  to  which  allusion  has  already  been 
made,a  Dr.  William  Stokes  pointed  out  that  the  virulence  of  the 
pustulation  and  the  tendency  to  pitting  are  directly  as  the  cutaneous 
vascularity  and  heat  of  surface.  In  proof  of  this  Stokes  instanced 
the  case  of  a  strong  and  healthy  young  woman,  who  was  admitted 
to  hospital  with  symptoms  of  fever,  including  intense  headache. 
°  See  Chapter  VIII.,  page  84. 


1  1  6*  SMALLPOX. 

For  the  relief  of  tins  symptom  she  was  leeched  freely  on  the 
temples.  The  attack  proved  to  be  one  of  confluent  smallpox,  but 
on  the  face  not  more  than  two  or  three  small  aborting  pustules 
made  their  appearance.  "  Who  can  doubt,"  asks  Stokes,  "  that  in 
this  instance  the  depletion  of  the  face  influenced  the  local  progress 
of  the  disease."  Again,  he  quotes  a  case  commented  on  by  Dr. 
Graves — that  of  a  man  who  contracted  smallpox  while  under  treat- 
ment in  one  of  the  surgical  wards  for  a  chronic  affection  of  the 
knee-joint.  The  affected  joint  was  strapped  with  mercurial  plaister, 
which  exerted  such  pressure  on  the  neighbouring  cutaneous  capil- 
laries as  absolutely  to  prevent  the  development  of  the  eruption  over 
the  part.  In  a  third  case  of  severe  confluent  smallpox  there  was 
great  tumefaction,  accompanied  with  extraordinary  heat  of  the 
face,  and,  in  the  hope  of  saving  the  eyes,  poultices  were  applied 
over  them.  The  patient  recovered,  but  with  deep  and  permanent 
pitting.  There  was,  however,  no  pitting  on  the  eyelids  or  in  their 
immediate  neighbourhood.  From  the  date  of  this  last  case  (1849) 
Stokes  adopted  as  a  routine  practice  the  application  of  light  poul- 
tices over  the  entire  face,  or  of  a  mask  of  lint  steeped  in  glycerine 
and  water  and  covered  with  a  corresponding  mask  of  oiled  silk. 
He  found  that,  with  but  one  exception,  pitting  was  effectually 
prevented.  In  that  case  the  patient  was  delirious,  and  could  not 
be  kept  from  tearing  the  poultices  off  his  face. 

As  the  outcome  of  his  observations,  Stokes  came  to  the  conclu- 
sion that,  if  from  an  early  period  we  protect  the  surface  from  the 
air  and  keep  it  in  a  permanently  moist  condition,  marking  will 
seldom  occur.  There  are  then  three  important  indications  of  treat- 
ment : — 

1.  The  exclusion  of  air. 

2.  The  keeping  of  the  parts  in  a  permanently  moist  state, 

so  as  to  prevent  the  hardening  of  the  scabs. 

3.  The  lessening  of  the  local  irritation. 

All  the  authorities  are  agreed  that  these  indications  should  be  as 
far  as  possible  fulfilled.  Dr.  Charles  West  recommends  strapping 
with  mercurial  plaister  or  sponging  with  a  solution  of  corrosive 
sublimate,  apparently  attributing  a  specific  action  to  the  mercury  in 


SMALLPOX.  117 

each  case.  But  for  this  there  seems  to  be  no  warrant.  Dr.  Alfred 
Hudson  used  to  smear  the  face  with  glycerine.  Sir  John  Banks, 
K.C.B.,  many  years  ago  suggested  the  application  of  an  ointment 
composed  of  lapis  calami nar is  (native  impure  carbonate  of  zinc)  and 
glycerine.  Dr.  Foot  applied  to  the  face  carbolised  oil — varying 
in  strength  from  1  in  4  to  1  in  8  parts ;  he  also  recommended 
the  application  of  flexible  collodion  to  the  papules  as  early  as 
possible,  for  its  late  application  only  does  mischief,  forcing  the 
pus  to  burrow  backwards  into  the  cutis,  so  increasing  the  der- 
matitis and  insuring  pitting.  Mr.  Marson,  of  the  London  Small- 
pox Hospital,  waited  until  the  pustules  had  burst  and  the  discharge 
had  begun  to  dry.  He  then  applied  the  best  olive  oil,  or  a  mixture 
of  glycerine  and  rose  water  in  the  proportion  of  1  in  3.  He 
also  recommended  "  cold  cream,"  or  oxide  of  zinc  ointment,  or  olive 
oil  and  lime  water  (linimentum  calcis,  or  "  Carron  oil ")  or  calamine 
mixed  with  olive  oil.  Curschmann  speaks  highly  of  the  value  of 
cold — even  iced — compresses  frequently  renewed  for  the  relief  of 
pain,  swelling  and  redness  of  the  skin.  The  American  practice  to 
prevent  pitting  is  exclusion  from  the  room  of  the  solar  light  and 
the  application  of  a  solution  of  boric  acid  (1  drachm  to  1  pint  of 
water)  by  means  of  compresses,  frequently  changed,  or  covered  with 
oiled  silk.  In  Germany  a  paste — composed  of  carbolic  acid,  4  to 
10  parts;  olive  oil,  40  parts;  and  prepared  chalk,  60  parts — is 
spread  on  linen  and  applied  to  the  parts  where  the  eruption  is  apt 
to  be  worst.  This  application  should  be  changed  every  twelve 
hours.3 

Dr.  Lewentauerb  suggests  the  application  to  the  face  by  means 
of  a  mask,  and  also  to  the  other  parts  on  which  the  eruption  is 
marked,  of  an  ointment  consisting  of  salicylic  acid,  3  parts  ;  starch, 
30  parts  ;  and  glycerine,  70  parts. 

Bertrandc  recommends  the  application,  with  a  brush,  as  soon  as 

a  Outlines  of  Medical  Treatment.  By  Samuel  Fenwick  and  W.  Soltau 
Fenwick.     Third  Edition.     London  :  J.  &  A.  ChurchilL     1891.     Page  449. 

b  Bulletin  Oen.  de  Thcrapeutique.     No.  32.     1889. 

0  Gazette  des  Hdpitaux.  Paris.  July  15  and  17,  1890,  and  Sajous'  Annual 
of  the  Universal  Medical  Sciences.     1891.     Vol.  I.     H.— ?2. 


118 


SMALLPOX. 


the  eruption  appears  either  on  the  face  or  in  the  pharynx  of  a 
mixture  of  4  grammes  (1  drachm)  of  boric  acid  to  50  grammes 
(1^  ounces)  of  glycerine.  The  eyes,  meanwhile,  should  be  bathed 
with  a  tepid  saturated  solution  of  boric  acid. 

Talamon3,  applies  ethereal  solutions  of  various  antiseptics  by 
means  of  a  spray  apparatus.  Salol  does  well  only  when  the  rash 
is  slight  and  scanty ;  in  all  cases  corrosive  sublimate  is  to  be  pre- 
ferred. He  sprays  the  part  for  a  minute  3  or  4  times  a  day — until 
desiccation  takes  place — with  a  solution  consisting  of  corrosive  sub- 
limate and  citric  acid,  of  each  one  gramme  (15*432  grains),  alcohol 
(90  per  cent.)  5  cubic  centimetres  (80  minims),  and  ether,  suffi- 
cient to  make  50  cubic  centimetres  (1^  ounces).  The  eyes  should 
be  guarded  during  the  application. 

Skoda  prefers  compresses  moistened  with  solution  of  corrosive 
sublimate  (gr.  2-4  to  water  §vj.).  Hebra  applies  only  cold  water 
compresses. 

My  own  plan  is  to  apply  over  the  face  a  light  mask  of  lint 
thoroughly  soaked  in  a  mixture  of  iced  water  and  glycerine  (a 
teaspoonful  in  an  ounce  of  water)  and  covered  with  oiled  silk. 

Closely  akin  to  these  various  measures  for  lessening  the  irritation 
of  the  surface,  keeping  the  eruption  moist,  and  excluding  air,  is 
the  treatment  of  smallpox  by  the  warm  or  tepid  bath. 

In  his  classical  "Essay  on  Fevers,"  b  Dr.  John  Huxham  advises 
bathing  not  only  the  legs  and  feet  but  the  arms  and  hands — "  nay, 
and  even  the  trunk  of  the  body  also,"  in  certain  cases  of  smallpox. 
His  object,  it  is  true,  was  to  bring  out  the  eruption  well.  He 
adds  :  "  This  is  not  altogether  a  new  method  :  for  Rhazesc  advises 
the  patient  to  be  kept  in  a  kind  of  Balneum  Vaporis,  to  facilitate 
the  eruption." 

Hebra  appears  to  have  had  his  attention  drawn  to  the  treatment 
of  smallpox  by  the  warm  bath  through  observing  its  efficacy  in  the 
management  of   burns.     In   his   practice  in  the  Vienna   General 

a  La  Medecine  Mcderne.     Paris.    April  17.  1890.    And  Sajous'  Annual  of  the 
Universal  Medical  Sciences,  1891.     "Vol.  1.     H. — 71. 
b  London :  -T.  Hinton.     1764.     Pages  137-138. 
c  Vide  Rhazes  de  Variolis  et  Morbillis.     Cap.  vi.     Ex  editione  Mead. 


SMALLPOX.  119 

Hospital  patients  suffering  from  extensive  burns  have  been  kept 
in  the  warm  bath  continuously  for  one  hundred  days  with  good  effect. 
"It  is  clear,"  says  Dr.  Stokes,  "that  in  the  case  of  the  continued 
warm  bath  we  have  the  conditions  just  mentioned  completely  ful- 
filled, and  that,  too,  as  regards  the  entire  person  of  the  patient." 

In  the  paper  from  which  I  have  so  largely  quoted,  Dr.  Stokes 
details  a  case  in  illustration  of  the  use  of  the  warm-bath  treatment 
of  bad  smallpox.  So  graphic  and  striking  as  a  word-picture  is 
this  clinical  record  that  I  know  I  shall  be  excused  for  transcribing 
it  at  length  : — "  Not  many  years  since,"  wrote  Dr.  Stokes  (in  1872), 
"  one  of  our  students,  a  very  large  and  robust  man,  was  attacked 
with  smallpox,  which  soon  showed  itself  in  its  worst  characters. 
The  fever  at  first  was  very  hijjh,  and  the  head-swelling  and  vascu- 
larity of  the  face  intense.  The  eruption  was  universal,  while  the 
pustules  on  the  face  became  confluent  at  an  early  period. 

"  Delirium  set  in,  and  the  patient  tore  off  the  dressings  from  his 
face  so  often  that  we  desisted  from  their  further  application. 
After  the  tenth  day  the  condition  of  the  patient  was  most  appalling. 
The  delirium  continued,  the  circulation  became  every  day  weaker 
and  more  rapid,  notwithstanding  the  free  use  of  stimulants ;  the 
crusts  were  not  only  black,  but  on  the  legs  where  here  and  there 
there  was  less  confluence,  the  blackness  of  the  worst  purpura 
appeared — a  condition  held  by  Hebra  to  be  always  fatal.  The 
body  was  one  universal  ulcerous  sore,  and  the  agonies  of  the 
patient  from  the  adhesion  of  the  surface  to  the  bed-clothes  were 
not  to  be  described.  In  addition  to  the  usual  foetor  of  smallpox  in 
the  stage  of  decrustation,  which  was  present  in  the  highest  degree, 
there  was  an  odour  of  a  still  more  intensely  pungent  and  offensive 
character,  which  seemed  to  pass  through  the  bystander  like  a  sword. 
I  never  before  or  since  experienced  anything  similar.  Stimulants 
alone,  freely  and  constantly  employed,  seemed  to  preserve  the 
patient  alive ;  the  pulse  was  rapid,  weak,  and  intermittent,  and  for 
several  days  we  despaired  of  his  life. 

"At  this  juncture  I  happened  to  describe  the  case  to  my  col- 
league, Mr.  Smyly,  who  suggested  the  trial  of  the  warm  bath,  with 
the  view  of  relieving  the  terrible  suffering.     A  bath  in  which  he 


120  SMALLPOX. 

could  recline  was  speedily  procured,  and,  pillows  being  adjusted  in 
it,  we  lifted  the  sufferer  in  and  placed  him  in  the  recumbent  position. 
The  effect  was  instantaneous  and  marvellous.  The  delirium  ceased 
as  if  by  magic ;  it  was  the  delirium  of  pain,  and  the  patient  ex- 
claimed, '  Thank  God !  thank  God !  I  am  in  Heaven !  I  am  in 
Heaven  !  why  didn't  you  do  this  before  ?'  The  fcetor  immediately 
and  completely  disappeared,  so  that  on  entering  the  ward  no  one 
could  suppose  that  there  was  a  case  of  smallpox  in  it.  He  was 
kept  at  least  seven  hours  in  the  bath,  during  which  time  brandy 
was  freely  administered,  and  omitted  only  when  he  showed  sym- 
ptoms of  its  disagreeing  with  the  brain.  He  was  then  removed  to 
bed.  The  surface  was  clean,  and  in  many  places  the  sores  looked 
healthy  and  white.  The  bath  was  repeated  next  day,  after  which 
he  fell,  for  the  first  time,  into  a  tranquil  slumber.  From  this  time 
his  recovery  was  progressive,  delayed  only  by  the  formation  of 
abscesses  and  the  great  soreness  of  the  feet. 

"  That  this  gentleman's  life  would  have  been  sacrificed  but  for 
the  timely  use  of  the  bath,  few  who  have  had  any  experience  in 
prognosis  can  reasonably  doubt.  He  was  in  the  condition  of  a 
patient  every  portion  of  whose  skin  had  been  burned  and  ulcerated. 
The  pustulation  was  almost  universally  confluent ;  the  purulent 
matter  highly  putrescent ;  the  hemorrhagic  state  developed,  and 
the  nervous  system  suffering — in  fact,  he  had  every  symptom  of 
the  worst  putrid  absorption. 

"  This  case,"  adds  Stokes,  "  and  its  singular  result,  in  addition 
to  the  experience  of  Hebra,  justifies  the  recommendation  of  the 
use  of  the  bath." 

In  a  discussion  on  the  treatment  of  smallpox  at  the  Medical 
Society  of  the  College  of  Physicians  of  Ireland,  on  March  20, 
1872,  Dr.  Hawtrey  Benson,  Physician  to  the  City  of  Dublin 
Hospital,  detailed  a  very  similar  case  to  the  foregoing.a  The 
patient  was  kept  in  a  slipper-bath,  at  a  temperature  of  98°  F.  for 
five  hours  and  a  half.  He  was  then  put  to  bed  perfectly  free  from 
delirium,  and,  with  the  help  of  15  grains  of  chloral  (of  which  60 
grains  had  previously  had  no  effect),  he  slept  uninterruptedly  for 
a  Dublin  Journal  of  Med.  Science.    Vol.  MIL,  page  325.     1872. 


SMALLPOX.  121 

eight  hours.  The  case  progressed  from  that  time  forward  without 
the  slightest  check. 

Professor  Hebra's  apparatus  for  the  continual  bath  was  exhi- 
bited in  the  London  International  Exhibition  of  1862.  It  was  also 
fully  described,  with  an  illustrative  plate,  in  the  Wiener  allgemerne 
med.  Zeitung,  No.  43,  1861,  as  well  as  in  the  inventor's  work  on 
"  Diseases  of  the  Skin,"  translated  for  the  New  Sydenham  Society 
in  1866  by  the  late  Dr.  Hilton  Fagge  (Vol.  I.,  page  320).  The 
apparatus  consists  of  a  bath,  six  feet  long  by  three  feet  broad, 
made  of  wood  and  lined  with  copper  or  zinc.  Exactly  fitting  its 
interior  is  an  iron  frame  to  which  are  fastened  transverse  bands  of 
webbing,  as  in  an  ordinary  bed.  About  two  feet  from  one  end  of 
this  frame  is  attached  a  head-support,  which  moves  on  a  hinge 
and  can  be  fixed  at  any  angle  by  a  simple  piece  of  rack-work.  The 
frame  is  covered  with  a  blanket  and  is  also  provided  with  a  horse- 
hair pillow  ;  it  does  not  rest  on  fixed  supports,  but  is  suspended  in 
the  bath  by  cords  attached  to  it  at  each  end.  These  cords  pass 
over  two  small  rollers,  placed  one  at  the  head,  one  at  the  foot  of 
the  apparatus  and  provided  with  handles,  so  that  the  whole  bed 
can  easily  be  raised  or  lowered  within  the  bath.  At  the  head  of 
the  bath,  but  at  a  higher  level,  is  a  vessel  made  of  copper,  which 
can  be  heated  so  that  the  water  may  be  supplied  at  any  required 
temperature.  The  supply  pipe  enters  the  bottom  of  the  bath,  the 
escape-pipe  opening  into  it  at  the  water-level.  When  the  apparatus 
is  in  use  water  is  kept  flowing  constantly  through  it,  so  that  all 
impurities  are  rapidly  washed  away.  To  enable  the  face  to  be 
kept  continually  wet,  or  to  be  specially  irrigated,  additional  small 
tubes,  each  provided  with  a  rose,  are  connected  with  the  copper 
vessel  or  reservoir. 

Before  the  patient  is  placed  in  the  bath,  it  is  filled  with  warm 
water,  at  a  temperature  of  90°  to  100°  Fahr.,  according  to  his 
inclination.  A  wooden  cover,  upon  which  a  blanket  is  spread,  is 
put  over  the  lower  part  of  the  apparatus  while  the  patient  is  in 
the  bath.  If  it  is  desired  that  the  head  also  should  be  covered, 
this  is  easily  managed  by  roofing  in  the  head  of  the  bath  by  means 
of  hoops  upon  which  blankets  are  placed. 


122  SMALLPOX. 

Four  of  these  baths  were  put  up  in  the  General  Hospital  of 
Vienna  under  Prof.  Hebra's  supervision. 

The  treatment  of  such  affections  of  the  skin  in  smallpox  as 
bed-sores,  abscesses,  boils,  erysipelas,  and  gangrene,  consists  largely 
in  scrupulous  cleanliness  and  efficient  nursing.  The  body  linen 
should  be  frequently  changed.  The  patient  should  lie  on  a  water- 
bed,  or  a  woven-wire  mattress,  since  the  introduction  of  which 
into  our  hospital  wards  bed-sores  have  become  much  less  common 
than  before.  The  intense  pain  which  attends  the  formation  of 
pustules  upon  the  soles  of  the  feet  and  the  palms  of  the  hands  is 
due  to  the  thickness  of  the  epidermis,  which  is  with  difficulty 
raised  by  the  exudation  and  thus  causes  a  counter-pressure  on  the 
cutis.  Our  object  then  should  be  to  keep  these  parts  moist  and 
therefore  soft,  and  this  is  effected  by  wrapping  the  feet  and  hands 
in  wet  cloths  covered  with  oiled  silk  or  gutta  percha  tissue  as 
recommended  by  Hebra.a  If  this  is  done,  no  disagreeable  sensa- 
tions are  felt.  Writing  in  1764,  Huxham  said:  "I  would  recom- 
mend also  bathing  the  feet  and  legs  in  warm  water,  or  milk  and 
water,  for  a  few  minutes,  two  or  three  times  a  day  before  and  at 
the  eruption,  and  would  likewise  have  cataplasms  of  milk  and  bread, 
b'tiled  turnips,  or  the  like,  applied  to  the  feet."  b  He  did  this  ''  to 
make  a  very  powerful  revulsion  from  the  head  and  breast." 

The  eyelids  should  be  poulticed  to  reduce  oedema,  or  kept  covered 
with  cold  compresses.  For  atrophic  keratitis  cod-liver  oil,  iron, 
wine,  and  good  food  are  indicated. 

Affections  of  the  mouth,  tongue,  and  pharynx  are  best  treated 
with  ice,  antiseptic  sprays  of  sulphurous  acid,  chlorinated  soda 
solution,  corrosive  sublimate  solution,  or  Condy's  fluid  well  diluted, 
antiseptic  gargles  of  quinine,  chlorate  of  potassium,  boric  or  lactic 
acid,  carbolic  acid,  and  so  on ;  linctuses  of  glycerine  of  tannin  or 
of  carbolic  acid,  boric  acid,  &c. 

In  cases  of  laryngitis  the  internal  use  of  ice  is  invaluable. 
Hot  poultices  should  be  slung  round  the  neck  and  kept  smeared 
with  glycerine  of  carbolic  acid  or  a  2^  per  cent,  carbolised  oil. 

a  Diseases  of  the  Skin.     New  Syd.  Soc.     1866.     Vol.  I.,  page  266. 
b  Essay  on  Fevers.     Page  136. 


SMALLPOX.  1 23 

In  the  early  stage  leeches  may  be  applied  to  the  angle  of  the  jaw. 
In  like  cases  in  scarlatina  Graves  recommended  the  application  of 
relays  of  sponges  wrung  out  of  hot  water  to  the  front  of  the  neck 
for  15  or  20  minutes  at  a  time.  Above  all,  the  steam  kettle  should 
be  kept  going  and  the  patient  should  be  placed  in  a  croup-tent 
and  well  supported  by  food  and  stimulants.  In  acute  oedema  of 
the  glottis,  Curschmann  advises  that  an  emetic  should  be  given, 
if  the  patient  is  strong  enough,  or  local  scarifications  or  trache- 
otomy may  be  employed. 

The  same  measures  as  those  advised  for  laryngitis  may  be 
adopted  in  bronchitis  or  other  affections  of  the  respiratory  tract, 
in  addition  to  dry-cupping  (if  the  rash  is  not  thick-set)  and  poul- 
ticing. 

Diarrhoea  is  often  controlled  by  a  starchy  diet  and  brandy  or 
port  wine,  and  by  poulticing  the  abdomen.  If  not,  solution  of 
pernitrate  of  iron  may  be  prescribed,  or  pills  of  acetate  of  lead  and 
opium,  or — in  the  case  of  children — aromatic  chalk  powders. 

In  cases  of  sleeplesssness  and  delirium,  the  hair  should  be  cut 
close  or  the  head  shaved,  ice  may  be  applied  as  recommended  by 
Stokes,  unless  there  is  much  depression,  and  stimulants  often  agree. 
The  drugs  mentioned  in  Chapter  V.  may  be  prescribed  according 
to  circumstances.  Attendants  upon  smallpox  patients  should  always 
be  on  their  guard  against  homicidal  or  suicidal  attempts. 

Curschmann  recommends  that  chloral  hydrate  should  be  admi- 
nistered by  the  rectum,  in  an  enema  containing  from  one  and  a 
half  to  two  drachms,  with  eight  ounces  each  of  water  and  of 
mucilage.  He  says  that  variolous  affections  of  the  pharynx  and 
larynx  may  be  dangerously  intensified  by  this  drug. 

Lastly,  while  only  too  often  it  happens  that  all  our  efforts  to 
combat  hemorrhagic  smallpox  are  in  vain,  we  yet  may  save  life 
by  the  administration  of  the  solution  or  tincture  of  ferric  chloride 
in  full  doses — 30  minims  every  third  hour,  or  of  gallic  or  tannic 
acid  in  5  to  10  grain  doses,  or  of  pyrogallic  acid,  in  one  grain 
doses,  or  of  ergot  (ounce-doses  of  the  infusion  or  3  grains  of  ergotin 
dissolved  in  glycerine  and  water,  the  latter  dose  being  given  hypo- 
dermically  if  need  be),  or— best  of  all— of  turpentine  and  ergot. 


124  SMALLPOX. 

The  formula  for  the  last  combination  which  we  used  at  Cork-street 
Hospital  was  as  follows  : — 

1^.  Extract.  Ergotse  Liquidi,  3i>i ; 
Olei  Terebinthinaa,  3iii  5 
S[)t.  vEtheris  Nitrosi,  3ii  5 
Spt.  Rectificati,  §i ; 
Ovi  Vitellum  ; 

Aquae  Menth.  Piperita?,  ad  gviii. 
Signa :  One  eighth  part  every  3rd,  4th,  or  6th  hour,  as  required. 
At  Cork-street  Hospital,  also,  in  menorrhagia  and  metrorrhagia, 
cold  to  the  vulva  was  of  use,  also  slapping  the  buttocks  with  cloths 
dipped  in  ice-cold  water.  In  several  cases,  hot  water  injected  into 
the  vagina,  as  recommended  by  Dr.  Emmett  of  New  York — the 
temperature  of  the  water  being  from  98°  to  110°  F. — and  cordially 
approved  by  Dr.  Lombe  Atthill,  seemed  to  do  good. 

In  these  awful  cases,  stimulants  are  imperatively  called  for — 
brandy,  whisky,  or  wine  according  to  circumstances,  and  especially 
"  egg-flip  "  mixture  and  "  turpentine  punch."  Curschmann  recom- 
mends a  further  trial  of  transfusion  of  blood,  which,  he  admits, 
has  so  far  disappointed  expectation. 


125 


CHAPTER  XII. 
Varicella,  or  Chickenpox. 

Nomenclature. — Derivation  of  the  term  "  Chickenpox." — Definition. — 
^Etiology  (historical  sketch). — Clinical  History  :  Incubation,  Invasion,  Erup- 
tion, Desiccation. — -No  secondary  Fever. — Not  a  fatal  Disease. — Complications 
and  Sequelae  :  Varicella  gangrenosa  (Jonathan  Hutchinson). — Dermatitis 
gangrenosa  —  "  Varicella-prurigo  "  (J.  Hutchinson).  —  Diagnosis  from  Lichen, 
Herpes,  Pemphigus,  and  Varioloid. — Prognosis  and  Treatment. 

Nomenclature.  —  Chickenpox. —  Synon.  : — Varicella,  Crystalli. 
Germ,  die  Wasserpocken,  Windblattern,  or  die  fliegende  Blatter  ; 
Fr.  Petite  verole  volante,  La  Verolette  (Hatte),  or  Varicelle ;  ltd. 
Ravaglione ;  Eng.  Waterpock  or  Glasspock.  The  term  Chicken- 
pox  is  supposed  by  Dr.  Hilton  Fagge  to  be  a  corruption  of  Chick- 
pease,  the  French  Pois  chiches,  dwarf-peas,  or  briefly  Chiche  from 
the  Latin  Cicer,  the  chick-pea. 

Definition. — An  acute  specific  and  highly  infectious  febrile 
disease,  especially  of  infancy  and  early  childhood,  not  dangerous 
to  life,  characterised  by  the  appearance  on  the  skin  of  successive  crops 
of  clear,  colourless,  watery  vesicles.  It  is  a  separate  and  distinct 
disease  from  smallpox — a  disease  sui  generis.  The  accompanying 
fever  is  moderate  as  a  rule  and  of  a  remittent  type,  increasing  and 
abating  with  the  coming  and  going  of  the  vesicular  rash. 

^Etiology. — Varicella  is  essentially  a  disease  of  childhood,  and 
usually  occurs  before  the  first  dentition  is  completed.  Even  suck- 
lings may  be  attacked,  but  among  children  over  ten  years  of  age 
the  disease  is  infrequent.  Thomas,a  of  Leipzig,  never  saw  an  adult 
suffering  from  varicella.  Baader,b  of  Bale,  carefully  noted  581 
cases — 382  occurred  in  children  aged  from  1  to  5  years ;  191,  from 
6  to  10 ;  7,  from  11  to  15  ;  2,  from  16  to  20 ;  and  2  (?),  from  20 
to  40.  Two  years  ago,  a  friend  of  mine,  aged  25  years,  himself  a 
member  of  the  medical  profession,  had  in  Dublin  a  well-marked 
attack  of  varicella. 

a  Von  Ziemssen's  Cyclopaedia  of  the  Practice  of  Medicine.  Vol.  II.  Acute 
Infectious  Diseases.     Art.  "Varicella." 

6  Jahrbuch  fur  Kindirheilkunde.     XVII.,  page  104. 


126  CHICKENPOX. 

Varicella  shows  itself  sporadically  (in  isolated  cases)  or  in 
moderate  and  often-repeated  local  epidemics  quite  independently  of 
smallpox.  In  Germany,  Thomas  says  it  appears  yearly  or  even 
twice  a  year  with  great  regularity  shortly  after  the  opening  of  the 
"  Kinder-garten,"  or  Infant-schools.  Its  appearance  is  not  deter- 
mined by  season,  but  it  often  follows  in  the  wake  of  other  specific 
fevers — scarlatina  especially. 

It  is  supposed  that  the  virus  is  generally  inhaled.  Its  tenacity 
of  life  does  not  seem  to  be  great :  hence,  perhaps,  the  limited 
spread  of  its  epidemics.  The  contents  of  well-marked  varicella 
vesicles  have  been  inoculated  with  negative  results  by  Heim, 
Vetter,  Czakert,  Fleischmann,  and  Thomas,  in  Germany;  Boyce,  in 
Edinburgh ;  and  J.  Lewis  Smith  in  America.  Hesse,  of  Leipzig, 
occasionally  succeeded  in  inoculating  varicella,  and  Steiner  was  also 
successful  in  8  out  of  10  cases  reported  in  the  Wiener  med.  Wochen- 
schrift,  No.  16,  for  1875.  In  marked  contrast  with  its  practical 
non-inoculability  stands  the  facility  of  its  dissemination  among 
little  children  by  contagion.  As  a  rule  chickenpox  does  not  recur, 
but  Trousseau  says  that  second  attacks  are  not  uncommon,  and 
Gerhardt  is  said  to  have  seen  it  recur  for  the  third  time. 

The  nature  of  the  specific  virus  of  varicella  is  as  yet  unknown. 
Dr.  A.  Tschamera  claims  to  have  isolated  a  hitherto  unknown 
micrococcus,  which  he  considers  stands  in  a  causal  relation  to  the 
disease.     But  no  definite  conclusions  have  so  far  been  arrived  at. 

The  earliest  authentic  descriptions  of  varicella  date  from  the 
middle  of  the  sixteenth  century.  About  the  year  1550  two 
medical  writers,  Vidus  Vidius  and  Ingrassias  of  Naples  de- 
scribed the  disease  under  the  name  "  Crystalli,"  in  reference,  no 
doubt,  to  the  clear,  crystal-like  contents  of  the  chickenpox  vesicles. 
The  Italian  synonym  was  Ravaglione.  The  malady  was  first  fully 
described  and  differentiated  in  England  by  Heberden  in  1766 
under  the  name  of  "  Variolse  pusillse."  His  paper  was  published 
in  the  first  volume  of  the  "Medical  Transactions  of  the  Royal 
College  of  Physicians,"  1767.  In  it  he  pointed  out  the  chief  reason 
which  made  the  recognition  of  chickenpox  a  matter  of  importance — 
a  Archiv.  f.  Kinderheilkunde.     Band  II.     Heft  3. 


CHICKENPOX.  127 

namely,  that  those  who  had  it  might  otherwise  be  deceived  into  a 
false  security  "  which  mipht  prevent  them  either  from  keeping  out 
of  the  way  of  the  smallpox  or  from  being  inoculated"  (Hilton 
Fagge).  Two  years  previously,  in  1764,  Vogel  is  said  to  have 
introduced  the  name  of  "Varicella,"  which,  like  "  Variola,"  is  a 
diminutive  of  the  Latin  varus,  a  pimple. 

Clinical  History. 

I.  Stage  of  Incubation. — The  stage  of  latency  is  believed  to  be 
on  an  average  about  as  long  as  that  of  smallpox — namely,  12  days. 
Makunaa  states  that  it  varies  from  8  to  17  days.  Bristowe  saysb 
that  in  some  cases  it  lasts  exactly  a  week,  but  perhaps  more  com- 
monly a  fortnight.  According  to  Thomas  it  varies  from  13  to  17 
days,  while  Trousseau  extends  its  duration  to  from  15  to  27  days. 
On  the  other  hand,  Gregory  limited  it  to  from  4  to  7  days. 
The  discrepancy,  in  Dr.  Hilton  Fagge's  opinion,  arises  from  the 
fact  that  the  length  of  the  incubation  has  in  general  been  calculated 
upon  the  veiy  precarious  basis  of  the  interval  between  the  dates  at 
which  different  children  of  the  same  family  have  been  successively 
attacked.  Towards  the  close  of  this  stage  there  is,  according  to 
Thomas,  in  some  cases  a  slight  rise  of  temperature. 

II.  Stage  of  Invasion. — This  stage,  also  called  that  of  the 
"Prodromal  Fever,"  is  badly  marked  in  varicella.  It  often 
happens  that  the  child  feels  perfectly  well  until  the  rash  appears. 
In  other  cases,  however,  malaise,  loss  of  appetite,  a  feeling  of  sick- 
ness, headache,  chilliness,  and  muscular  pains  precede  the  eruption 
by  a  few  hours,  or  one  to  even  three  days.  The  "Prodromal 
Fever"  is  usually  very  slight,  but  occasionally  a  sudden  rise  of 
temperature  to  101°,  or — in  severe  cases — even  to  104°  takes  place 
just  before  the  rash  appears.  Once  Thomas  observed  a  transitory 
general  erythema  with  a  temperature  above  106°  F.,  but  such  an 
occurrence  is  quite  exceptional. 

III.  Stage  of  Eruption. — This  may  be  ushered  in  by  a  roseolar 
scarlatiniform  rash,  but  the  true  eruption  consists  of  papules  or 
measles,  like  the  rose  spots  of  typhoid  (Trousseau),  and  deleble  on 

a  Lancet,  Vol.  II.,  page  350.     1375. 

h  Theory  and  Practice  of  Medicine.     Seventh  Edition.     1890.     P.  186. 


128  CHICKENPOX. 

pressure  (Gee),  which  rapidly  change  into  vesicles.  These  do  not, 
under  ordinary  circumstances,  become  pustular  and  are  unaccom- 
panied by  an  inflammatory  areola.  The  vesicles  appear  first  on 
the  trunk,  especially  the  chest,  then  on  the  face  and  scalp,  finally 
on  the  limbs.  They  increase  in  size  up  to  the  third  or  fourth  day, 
when  they  are  about  as  large  as  split  peas.  They  become  acum- 
inated or  conoidal,  and  finally  burst,  shrivel,  and  dry  up.  They 
are  not  markedly  umbilicated  and  are  said  to  be  not  divided  into 
compartments  (loculi)  like  the  pustules  of  smallpox.  According  to 
their  shape,  they  were  described  by  Willan  and  Bateman,  in  their 
work  on  Skin  Diseases,  published  in  1806,  as  lenticular,  conoidal,  or 
globate.  They  contain  a  clear,  watery,  but  afterwards  straw- 
coloured  lymph.  Dr.  Hilton  Fagge  describes  the  vesicles  as 
sometimes  having  a  red  base,  but  sometimes  being  seated  upon  a 
perfectly  colourless  surface,  so  that  the  patient  looks  exactly  as  if 
he  had  been  sprinkled  with  drops  of  clear  water. 

When  air  exists  under  the  roof  of  the  vesicle,  it  has  always 
entered  through  some  aperture  from  without  (Varicella  ventosa, 
emphysematosa;  Windpox). 

The  visible  mucous  membranes,  as  well  as  the  skin,  are  the  seat 
of  an  eruption.  Thus,  vesicles  are  not  uncommonly  seen  on  the 
buccal  mucous  membrane,  the  hard  and  soft  palates,  the  throat, 
lips  and  tongue,  the  conjunctiva?  and  gums  (Henoch),  and  the 
genital  mucous  membrane  in  girls  (Thomas). 

The  febrile  movement  is  not  acute — indeed  in  some  very  mild 
cases  there  is  a  complete  absence  of  fever.  Usually,  however,  the 
fever  is  remittent,  increasing  at  night  (Trousseau),  and  in  propor- 
tion to  the  amount  of  the  rash,  which  may  continue  to  come  out  in 
successive  crops  for  even  10  or  12  days.  In  Willan  and  Bate- 
man's  Delineations  of  Cutaneous  Diseases  there  are  two  very  good 
Plates  illustrative  of  these  appearances.  Defervescence,  when  it 
occurs,  is  usually  rapid  (Hilton  Fagge). 

IV.  Stage  of  Desiccation. — This  stage,  or  process,  varies  in 
duration  owing  to  the  development  of  the  eruption  in  successive 
crops  of  vesicles.  In  the  case  of  individual  vesicles,  desiccation 
takes  place  rapidly,  the  vesicular  contents  being  partly  absorbed 


CHICKENPOX.  129 

and  partly  extravasated  through  bursting  of  the  vesicle.  A  pit, 
or  scar,  may  be  left  when  the  vesicle  has  become  a  pustule.  A 
good  example  of  this  is  represented  in  Plate  XXXII.  of  the  New 
Sydenham  Society's  Atlas  of  Skin  Diseases. 

Unless  in  very  rare  instances,  there  is  no  secondary  fever,  and 
the  disease — if  uncomplicated — seldom  or  never  destroys  life. 

According  to  Trousseau  and  Canstatt,  relapses  in  varicella  are 
frequent,  but  Thomas  never  saw  a  true  relapse — that  is,  the  renewed 
appearance  of  the  disease  in  its  totality,  and  he  rightly  looks  upon 
cases  of  so-called  relapse  as  being  really  examples  of  recurrent 
crops  of  the  rash. 

Complications  and  Sequelae. — These  may  almost  be  said  not  to 
exist,  but  in  a  communication  to  the  Royal  Medical  and  Chirurgi- 
cal  Society  on  Tuesday,  October  25, 1881,  Mr.  Jonathan  Hutchinson, 
F.R.S.,  drew  attention  to  a  formidable  and  very  dangerous,  though 
happily  rare,  variety  of  the  disease,  to  which  he  gave  the  name  of 
"Varicella  gangrgenosa."  This  malady,  according  to  him,  was 
well-known  in  Ireland  in  past  times  under  the  names  of  the 
"  White  Blisters,"  the  " Eating  Hive,"  and  the  "Burnt  Holes." 
In  proof  of  this,  reference  was  made  to  a  paper  written  by  Dr. 
Whitley  Stokes,  of  Dublin,  in  1807,  in  which  he  proposed  for  the 
disease  the  name  of  "Pemphigus  gangrsenosus." a 

"  This  dangerous  form  of  the  disease,"  writes  Dr.  Eustace  Smith,15 
"  is  not  confined  to  weakly,  ill-nourished  children,  but  is  most 
common  in  them.  It  is,  no  doubt,  connected  with  the  curious  ten- 
dency to  spontaneous  gangrene  sometimes  met  with  in  children." 
According  to  several  observers,  this  condition  often  attends  acute 
miliary  tuberculosis. 

"  In  gangrenous  varicella,"  proceeds  Dr.  Eustace  Smith,  "  the 
vesicles,  instead  of  drying  up  in  the  ordinary  way,  become  black 
and  get  larger,  so  that  a  number  of  rounded  black  scabs,  with  a 
diameter  of  half  an  inch  to  an  inch,  are  scattered  over  the  sui'face 
of  the  body.     If  a  scab  be  removed,  it  is  seen  to  cover  a  deep 

a  The  Lublin  Medical  and  Physical  Essays.  Dublin  :  Gilbert  &  Hodges. 
Vol.  I.     1808.     Pp.  146,  et  seq. 

b  Disease  in  Children.     New  York.     1884.     Page  49. 

K 


]  30  CHICKENPOX. 

ulcer.  Around  it  the  skin  is  of  a  dusky  red  colour.  All  the 
vesicles  do  not  take  on  the  gangrenous  action,  so  that  we  find 
many  varicellous  scabs  of  ordinary  appearance  mixed  up  with  the 
blackened  crusts.  The  gangrenous  process  often  penetrates  deeply 
through  the  skin  to  the  muscles,  but  under  some  of  the  scabs  the 
ulceration  is  more  shallow.  These  cases  are  very  fatal.  Mr. 
"Warrington  Howard  has  reported  the  case  of  a  weakly  baby  twelve 
months  old,  who  weighed  only  six  pounds  and  a  half.  The  child 
was  attacked  with  gangrenous  varicella  and  died  in  a  few  days  of 
pyaemia  with  secondary  abscesses  in  the  lungs." 

Dr.  Radcliffe  Crocker  points  out  {Lancet,  May  30,  1885)  that 
this  gangrenous  eruption  may  occur  in  parts  not  the  seat  of  the 
varicellous  rash,  and  it  is — in  fact — well  known  and  described  as 
Dermatitis  gangrenosa  by  various  writers.  I  have  myself  seen  a 
most  remarkable  case  of  the  affection  in  a  young  lady,  who  for  years 
suffered  from  urgent  gastric  symptoms,  apparently  of  neurotic  origin. 
Hutchinson,  in  his  paper,  states  that  loss  of  sight  may  occur  from 
purulent  irido-choroiditis  in  the  course  of  gangrenous  varicella. 

According  to  Hilton  Fagge,  it  is  a  question  whether  the  early 
stage  of  vesicular  strophulus  is  to  be  regarded  as  distinct  from 
chickenpox.  If  not,  the  favourable  prognosis  which  is  allowed  by 
all  writers  must  to  some  extent  be  modified,  for  whereas  they  speak 
of  varicella  as  always  ending  in  recovery,  one  of  Hutchinson's 
cases  of  "  Varicella-prurigo  "  terminated  fatally.  This  is  a  remark- 
able skin  affection  which  Mr.  Hutchinson  thinks  arises  out  of 
varicella,  but  which  Hilton  Fagge  believes  to  be  an  exaggerated 
form  of  Strophulus,  or  Red  Gum. 

Diagnosis. — Chickenpox  may  be  confounded  with  lichen,  herpes, 
pemphigus,  and  varioloid.  The  vesicles  may  be  somewhat  clustered 
together,  as  in  herpes.  Trousseau  speaks  of  an  epidemic  in  the 
Jsecker  Hospital,  Paris,  in  which,  during  from  15  to  40  days,  blebs 
or  bullce  like  those  of  pemphigus  kept  appearing  on  different  parts 
of  the  patients'  bodies,  leaving  ulcerations  which  lasted  for  six 
weeks  or  two  months.  From  the  three  first-named  skin  affections 
chickenpox  is  sufficiently  distinguished  by  the  age  of  the  patients, 
their  previous  history,  and  the  course  of  the  disease.     It  is  of  the 


CHICK ENPOX.  13 L 

first  importance  to  correctly  diagnosticate  varicella  from  small- 
pox. In  cases  of  doubt,  it  will  be  better  for  the  physician  to  act 
as  if  the  disease  were  really  varioloid,  in  order  to  protect  the 
community. 

At  this  time  of  day,  it  seems  hardly  necessary  to  insist  that 
varicella  is  a  disease  of  its  own  kind  {mi  generis),  absolutely  distinct 
from  smallpox  in  all  respects.  But  the  glamour  which  attaches  to 
the  name  of  the  great  dermatologist  of  Vienna — Hebra,  and  to 
that  of  his  son-in-law,  Kaposi — both  of  whom  refuse  to  recognise 
the  separate  identity  of  chickenpox,  render  imperative  a  statement 
of  the  grounds  upon  which  a  differential  diagnosis  is  based.  Of 
these  the  principal  are  here  given  after  Trousseau's  account,  con- 
tained in  his  masterly  Clinique  Medicate  de  V Hotel  Dieu:— 

1.  Chickenpox  has  often  prevailed  epidemically  without  small- 

pox. Mohl,  for  example,  states  that  from  1809  to  1823 
chickenpox  was  annually  observed  at  Copenhagen,  from 
which  smallpox  was  absent.  On  the  other  hand,  varioloid 
has  never  been  prevalent  without  coincident  smallpox. 

2.  As  to  age,  very  young  children  are  attacked  by  chickenpox, 

whereas  smallpox  in  a  population  protected  by  vaccination 
usually  shows  itself  in  adults. 

3.  Chickenpox  had  been  described  and  known  long  before  the 

introduction  of  vaccination,  previously  to  which  date  vario- 
loid was  rarely  met  with. 

4.  Vaccinated  children  readily  take  chickenpox,  not  so  smallpox, 

even  in  the  form  of  varioloid. 

5.  Children  who  have  had  chickenpox  may  contract  smallpox 

even  soon  afterwards.  In  the  Lancet  for  1877  a  case  is 
recorded  of  an  nnvaccinated  child,  who  was  admitted  into 
St.  Thomas's  Hospital  for  chickenpox,  but  who  was  placed 
on  the  floor  containing  the  smallpox  wards  because  the 
diagnosis  was  at  first  uncertain.  Two  days  afterwards  vacci- 
nation was  performed,  which  succeeded.  Eight  days  later 
still  the  child  fell  ill  with  modified  smallpox  (Hilton  Fagge). 

6.  The  two  diseases  may  co-exist.     In  1845,  Dr.  Delpech  pub- 

lished a  case  of  this  kind. 


132  CHICKENPOX. 

7.  The  virus  of  chickenpox  never  gives  rise  to  smallpox,  and 

the  converse  of  this  proposition  is  believed  to  be  equally  true. 

8.  Chickenpox  is  generally  held  to  be  non-inoculable,  whereas 

smallpox  is  notoriously  inoculable. 

9.  Second  attacks  of  chickenpox  are  not  uncommon,  while  small- 

pox rarely  occurs  twice  in  the  same  person. 

10.  The  eruption  of  chickenpox  may  set  in  after  24  hours,  that 

of  varioloid  is  postponed  to  the  fourth  or  fifth  day. 

11.  The  febrile  movement  in  chickenpox  continues  after  the  spots 

appear,  that  in  varioloid  subsides. 

12.  In  chickenpox  the  spots  come  out  in  successive  crops  and 

the  fever  is  slight  and  remittent. 

13.  The  characters  of  the  spots  are  essentially  different  in  the 

two  diseases. 

14.  Chickenpox  is  not  a  deadly  disease,  whereas  even  the  mildest 

form  of  smallpox  may  prove  fatal. 

The  interested  reader  will  find  an  excellent  statement  by  Dr. 
Samuel  Jones  Gee  of  the  arguments  in  favour  of  the  non-identity  of 
varicella  and  variola  in  Vol.  I.  of  Reynolds's  System  of  Medicine. 

Prognosis  and  Treatment. — The  simplest  measures  suffice  in 
the  management  of  a  disease  which  is  generally  so  harmless  that 
Thomas  thinks  that  any  prophylactic  isolation  of  the  patient  is 
quite  needless.  In  passing,  I  may  state  that  I,  for  one,  do  not 
concur  in  this  view.  Dr.  Douglas  Powell a  considers  that  eczematous 
eruptions  after  varicella,  with  concurrent  swollen  glands,  may  lead 
to  the  development  of  phthisis.  All  that  is  necessary  in  a  case  of 
ordinary  chickenpox,  however,  is  to  keep  the  child  indoors,  pre- 
scribe a  milk  and  broth  diet,  avoiding  strong  animal  foods,  and 
regulate  the  bowels  by  gentle  aperients.  Sir  William  Aitken 
recommends  stewed  prunes  or  baked  apples  to  fulfil  this  indication. 
We  should  further  give  mild  diaphoretics,  if  the  skin  is  dry  and 
itchy  and  the  fever  acute.  Lastly,  it  is  most  desirable  to  protect 
the  vesicles  as  far  as  possible  from  injury  by  rubbing  or  scratching, 
lest  a  secondary  and  more  severe  dermatitis,  resulting  in  scarring, 
should  be  set  up. 

a  On  Diseases  of  the  Lungs  and  Pleurce,  including  Consumption.  London  : 
H.  K.  Lewis.     Third  Edition.     1886.     Page  413. 


133 


CHAPTER  XIII. 
Morbilli,  or  Measles. 

Nomenclature. — Definition. — ^Etiology. — Bacteriology. — Chief  Stages  of 
Infectiveness. — Epidemics  in  Faroe  Islands  and  in  Figi. — Seasonal  Preva- 
lence :  Measles  a  disease  of  Spring  and  Autumn. — Clinical  History  : 
Incubation,  Invasion,  Eruption,  Desquamation. — Furfuraceous  Desquama- 
tion.— Convalescence  complete  on  the  Eighteenth  Day. 

Nomenclature. — Measles  (originally  Mesles  or  Maseles),a  cor- 
responding to  the  German  Maal,  marks  or  moles — and  Masern,  spots 
(the  Sanscrit  Masura,  spots),  ltal.  Morbilli  ("The  little  plagues," 
being  diminutive  of  II  Morbo,  the  plague) ;  Lot.  Rubeola  (so  called 
by  De  Sauvages,  1760);  Fr.  Rougeole;  Dutch,  Mazelen ;  Danish 
and  Norwegian,  Mreslinger ;  Swed.  Massling ;  Span.  Sarampion ; 
ltal.  Rosolia,  or  Roselia ;  Arabic,  Hhasbah  (Rhazes  and  Avicenna). 

Definition. — A  highly  infectious,  acute,  febrile  disorder,  usually 
setting  in  with,  and  throughout  accompanied  by,  catarrh  of  the 
mucous  membranes,  especially  those  of  the  eyes,  nose,  and  respira- 
tory passages ;  characterised  by  the  appearance  on  the  fourth  day 
of  a  deep  rose-red,  or  crimson  inclining  to  purple,  eruption  of  soft 
papules  or  pimples,  which  spreads  over  the  whole  body  in  the 
course  of  thirty-six  hours,  and  is  preceded  and  accompanied  by 
sharp  fever.  This  terminates  by  crisis  between  the  sixth  and 
eighth  days,  coincidently  with  the  fading  of  the  rash.  Conva- 
lescence is  apt  to  be  complicated  with  affections  of  the  glandular 
system  and  respiratory  organs. 

iEtiology. — The  question  of  the  native  seat  of  measles  baffles  all 
research  (Hirsch).  The  disease  was  probably  widely  diffused  over 
Europe  and  Asia  in  the  middle  ages,  and  at  the  pi'esent  day  the 
area  of  its  distribution  is  practically  conterminous  with  the  entire 
habitable  globe.  Its  separate  identity  was  first  shadowed  forth  by 
Forestus  (1563),  but  it  is  to  Sydenham  (1676)  that  we  owe  the 
full  differential  diagnosis  between  measles  and  smallpox. 

a  Joh.  Anglicus.     Praxis  Med.     Aug.     Vindel.     1595.     Page  1,041. 


134  MEASLES. 

Age  does  not  affect  the  occurrence  of  measles  as  much  as  is 
generally  supposed.  It  is  a  disease  of  all  ages,  although  Thomas 
rightly  declares  that  children  under  six  months  old  enjoy  a  con- 
siderable immunity,  or  rather  are  less  susceptible  to  the  disease. 
In  communities  unprotected  by  a  previous  outbreak,  measles  attacks 
individuals  of  all  ages. 

The  bacteriology  of  measles  is  scanty — the  authorities  on  the 
subject  up  to  the  present  being  Salisbury  {American  Journal  of  the 
Medical  Sciences,  1362a),  Keating  {Phil.  Med.  Times,  1882),  and 
Cornil  and  Babes  (Les  Bacte'ries,  1885).  According  to  Edgar  M. 
Crookshank,b  round  cocci  and  diplococci  have  been  observed  in  the 
catarrhal  exudations,  in  the  papules  and  in  the  capillary  vessels  of 
the  skin,  as  well  as  in  the  blood  of  patients  attacked  by  the  disease. 
The  materies  morbi,  therefore,  may  be  considered  to  exist  in  the 
expectoration  and  in  the  cutaneous  debris.  There  is  no  doubt  that 
measles  is  "  taking,"  or  infectious,  from  the  first  sneeze  or  cough — 
that  is,  from  the  very  beginning  of  the  initial  or  prodromal  stage  (in- 
vasion). Hence,  the  chief  difficulty  in  checking  its  spread  amongst 
the  members  of  an  attacked  household.  It  is  most  infectious, 
however,  in  the  eruptive  stage,  and  probably  not  very  infectious 
in  the  stage  of  desquamation.  Its  "  striking  distance  "  is  believed 
to  be  considerable,  but  the  contagium  is  less  persistent  than  that  of 
scarlatina  (Hilton  Fagge).  One  attack  usually,  but  not  necessarily, 
protects  from  a  second — acquired  immunity  is  not  so  constant  after 
measles  as  it  is  after  smallpox.  Measles  is  a  highly  infectious  and 
a  very  deadly  disease  when  it  attacks  an  unprotected  community — 
that  is,  a  community  not  leavened  with  the  virus  and  in  conse- 
quence not  immune.     Two  notable  illustrations  of  this  have  become 

a  Dr.  Salisbury,  of  Newark,  Ohio,  United  States,  many  years  ago  demon- 
strated his  ability  to  produce  a  disease  indistinguishable  from  measles  by 
means  of  musty  straw.  Dr.  Henry  Kennedy,  of  Dublin,  reported  in  the  Dubl. 
Journ.  of  Med.  Science  (Vol.  XXXV.,  1863,  p.  60),  a  case  in  which  a  disease 
like  measles  arose  in  connection  with  musty  linseed  meal.  Thomas,  of  Leipzig, 
disposes  of  Salisbury's  statement  that  the  rashes  produced  by  decaying  straw 
afford  protection  against  measles,  by  saying  that  it  "  is  not  to  be  believed  for 
a  moment." 

6  Manual  of  Bacteriology.  Second  Edition.  London  :  Lewis.  1887.  Page 
214. 


MEASLES.  135 

matters  of  medical  history  within  recent  times.  They  are  as 
follow : — 

In  the  spring  of  1846,  measles  was  accidentally  imported  from 
Copenhagen  into  the  Faroe  Islands,  which  had  enjoyed  an  immunity 
from  the  malady  for  sixty-five  years  (from  1781).  On  March  20  of 
that  year  a  workman  left  Copenhagen,  being  then  unwittingly  in  the 
incubation  stage  of  measles.  He  landed  in  the  islands  on  March 
28,  and  developed  symptoms  of  measles  on  April  1.  His  two  most 
intimate  friends  were  in  due  time  attacked,  and  the  malady  spread 
until  at  last  6,000  out  of  a  total  population  of  7,782  contracted  the 
disease.  Age  afforded  no  protection — old  men  and  women  fell 
victims  as  readily  as  young  children.  This  outbreak  is  of  special 
interest,  as  it  enabled  Dr.  Panum,  of  Copenhagen,  who  was  its 
historian,  to  make  a  series  of  most  valuable  investigations  into  the 
length  of  the  incubation  period  in  measles. 

In  1875  the  Fiji  Islands,  in  the  Pacific  Ocean,  were  annexed  to 
the  British  Crown.  From  the  Medical  Times  and  Gazette  of  June 
12  in  that  year,  we  learn  that  "the  first  advantage  (?)  derived  by 
annexation" — so  the  Fiji  papers  of  March  20,  1875,  describe  it — 
^  is  the  introduction  of  measles,  and  for  this  the  islanders  are 
indebted  to  H.M.S.  'Dido,'  which  came  down  and  discharged  her 
diseased  passengers,  utterly  regardless  of  any  consequences  that 
might  ensue."  The  disease  made  great  ravages  throughout  the 
whole  of  the  islands.  Tui  Levuka  and  other  chiefs  succumbed  to 
it,  and  even  the  hardy  mountaineers  in  the  interior  had  consider- 
able havoc  made  in  their  ranks.  The  germs  of  the  disorder  were 
taken  into  the  mountains  by  the  chiefs  who  had  been  brought  over 
to  Levuka — the  capital — and  entertained  on  board  the  Dido.  The 
disease,  which  was  almost  always  followed  by  dysentery  (morbillous 
colitis),  assumed  the  form  of  a  plague. 

Seasonal  Prevalence. — Although  like  smallpox,  apparently 
independent  of  climate — for  it  is  met  with  alike  amidst  Arctic 
snows,  in  temperate  latitudes,  and  under  the  tropical  sun — measles 
prevails  especially  in  the  spring  and  autumnal  quarters  of  the 
year.  An  analysis  of  the  weekly  returns  of  deaths  from  measles 
in  the  Dublin  Registration  District,  published  by  the  Registrar- 


1 36  MEASLES. 

General  for  Ireland,  long  since  led  me  to  the  conclusion  that  a 
mean  temperature  above  58*6°  was  not  favourable  to  the  spread  of 
this  disease,  and  that  a  mean  temperature  below  42*0°  was  equally 
inimical  to  its  prevalence.3.  These  results  are  in  strict  accord  with 
those  arrived  at  by  Dr.  Edward  Ballard,  who  saysb  that  the  only 
condition  concerned  in  the  arrest  of  the  spread  of  measles  in  summer 
is  the  rise  of  the  temperature  of  the  air  above  a  mean  of  60°  F., 
while  towards  winter  a  fall  below  42°  F.  also  distinctly  tends  to 
check  the  disease. 

The  accompanying  Diagram  (2),  copied  from  the  Annual  Summary 
of  Births,  Deaths,  and  Causes  of  Death  in  London  and  other  great 
towns  for  1890,  by  the  Registrar-General  for  England,  is  based 
upon  the  weekly  returns  of  deaths  from  measles  in  London  for  the 
fifty  years,  1841-1890,  inclusive.  In  it,  the  mean  line  represents 
an  average  weekly  number  of  34  deaths  from  the  disease  under 
discussion,  and  the  weekly  curve  shows  a  double  maximum  and  a 
double  minimum,  the  larger  maximum  falling  in  November, 
December,  and  January,  with  an  extreme  excess  of  50  per  cent,  in 
the  fourth  week  of  December,  and  the  smaller  in  May  and  June, 
with  an  extreme  excess  of  25  per  cent,  in  the  first  week  of  June. 
The  larger  minimum  falls  in  August,  September,  and  October — 
extreme  deficit  being  45  per  cent,  below  average  in  the  last  week 
of  September,  and  the  smaller  minimum  in  February  and  March — 
extreme  deficit,  30  per  cent,  below  average  in  the  third  week  of 
February. 

Clinical  History. — A  typical  case  of  measles  may  be  considered 
to  run  through  four  stages,  which  we  will  now  study  in  detail — they 
are,  in  chronological  order,  the  stages  of  incubation,  invasion, 
eruption,  and  desquamation. 

1.  Stage  of  Incubation. — Ten  days,  as  a  rule,  elapse  between 
the  reception  of  the  poison  into  the  system  and  the  manifestation 
of  the  earliest  febrile  and  catarrhal  symptoms,  or  fourteen  days 
between   infection   and  the  appearance  of  the  rash.     These  are 

a  Manual  of  Public  Health  for  Ireland.     1875.     Pages  300,  301. 
b  Eleventh  Report  of  the  Medical  Officer  of  the  Privy  Council.     1868.     No.  3. 
Pages  54-62. 


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MEASLES.  137 

Panum's  estimates,  based  on  his  observations  in  a  newly-infected 
community,  the  inhabitants  of  the  Faroe  Islands  in  1846.  Under 
other  circumstances,  the  determination  of  the  length  of  the  incuba- 
tive period  of  measles  must  be  attended  with  the  greatest  difficulty- 
owing  to  the  multiplicity  of  infecting  centres.  As  commonly 
happens  when  a  specific  virus  is  introduced  into  the  system  by  what 
may  be  called  "  a  short  cut,"  the  stage  of  incubation  is  shortened 
after  inoculation.  Hebra,  who  successfully  inoculated  with  the 
nasal  mucous,  found  that  in  such  cases  the  symptoms  showed  them- 
selves in  8  days,  the  difference  in  time  representing  the  effect  of 
the  resistance  offered  to  the  invading  virus  by  the  skin  and  mucous 
membrane. 

In  1876  I  had  an  opportunity  of  observing  a  case  of  measles 
even  from  the  stage  of  incubation,  and  the  following  facts  will  be 
of  interest : — On  March  26  in  that  year,  a  married  lady,  aged 
twenty-one,  fell  ill  of  measles.  Her  parlourmaid  had  sickened  with 
the  same  disease  ten  days  (inclusive)  previously,  that  is,  on  March  17. 
At  3  p.m.  of  the  26th,  Mrs.  A.  B.  felt  thirsty,  chilly,  and  fatigued. 
Her  appetite  failed.  The  rash  appeared  on  the  face  on  the  after- 
noon of  the  3 Oth  (5th  day),  the  fastigium  (103'4°  F.)  was  reached 
at  1  p.m.  of  April  1  (7th  day),  when  the  eyes  were  suffused  and  the 
rash  fully  out.  Defervescence  was  complete  on  April  3.  The  clinical 
chart  will  be  found  in  Plate  II.,  Fig.  1.  (See  page  146.)  In  this 
case  the  duration  of  the  latent  period  was  almost  certainly  10  days. 

In  the  spring  of  1877  both  measles  and  scarlatina  were  prevalent 
in  Dublin,  and  it  was  difficult  effectually  to  isolate  the  incoming 
cases  in  the  Epidemic  Wards  of  the  general  hospitals.  In  two 
instances  at  the  Meath  Hospital  scarlatina  patients  unfortunately 
contracted  measles  while  convalescing.  In  both  cases  the  symptoms 
of  measles  were  detected  on  the  eleventh  day  after  exposure  to  the 
contagium  of  that  disease — that  is,  on  the  eleventh  day  after 
admission  to  hospital.  The  clinical  charts  are  given  in  Plate  II., 
Figs.  2  and  3.     (See  page  146). 

Few  or  no  symptoms  attend  this  preliminary  stage.  Towards 
its  close,  fatigue,  lassitude,  and  nausea  may  be  felt,  and  the  pulse 
beats  faster  than   in   health.     At  this  time,  also,  an  ephemeral 


138  MEASLES. 

fever,  followed  by  defervescence,  has  been  noticed  by  Thomas,  of 
Leipzig. 

2.  Stage  of  Invasion. — The  initial  stage  is  longer  in  measles 
than  in  any  other  of  the  exanthemata.  It  lasts  4  or  5  days.  The 
disease  begins  suddenly  with  the  usual  nervous  symptoms  of  an 
acute  fever,  and,  in  addition,  a  remarkable  group  of  symptoms  con- 
nected with  the  mucous  membranes.  The  patient,  "  sickening  for 
measles,"  is  seized  with  shivering ;  or,  if  a  child,  perhaps  has  a 
fit  of  convulsions.  He  complains  of  lassitude,  headache,  and  pains 
in  the  joints.  The  skin  becomes  hot  and  dry,  the  pulse  beats 
quickly,  and  there  is  a  rapid  rise  of  temperature  to  102-5°  or  even 
104°  F.  by  the  evening  of  the  first  day.  This  "  initial  fever,"  as 
Wunderlich  calls  it,  is  usually  followed  by  an  equally  sudden  fall  of 
temperature,  so  that  by  the  morning  of  the  3rd  day  the  thermometer 
readings  are  normal  (98-4°)  or  only  slightly  febrile  (99°  or  100°). 
As  the  eruptive  stage  approaches,  a  fresh  rise  of  temperature  begins. 
The  physician  should  be  on  his  guard  against  mistaking  the  initial 
or  prodromal  fever  of  measles  for  a  mere  febricula  or  ephemeral 
fever  of  non-specific  origin. 

But  it  is  the  catarrhal  symptoms  which  are  so  eminently 
characteristic  as  to  be  pathognomonic  of  measles.  From  the  outset 
the  patient  sneezes,  the  eyelids  itch  and  swell,  and  become  very 
red  on  the  inside  ;  the  eyes  water  (lacrymatiori),  look  bloodshot  and 
shun  the  light  {photophobia.)  A  flow  of  acrid  tenacious  mucus  takes 
place  from  the  nostrils,  the  nose  seems  stopped  up  and  then  often 
bleeds  (epistaxis),  and,  in  a  word,  the  individual  seems  to  be  suffering 
from  a  "  bad  cold  in  the  head  "  (coryzd).  At  the  same  time,  the 
throat  feels  raw  and  sore,  the  voice  becomes  husky,  and  a  hoarse, 
brassy  cough  sets  in,  occurring  in  paroxysms  or  "  kinks."  Simul- 
taneously there  is  a  catarrhal  diarrhoea  in  many  cases,  the  motions 
being  green  and  unhealthy-looking.  On  the  second  day  an 
efflorescence  may  spread  over  the  skin,  leading  to  a  wrong  diagnosis 
of  scarlatina.  This  accidental  rash  may  also  simulate  urticaria 
because  of  the  itchiness  which  accompanies  it.  It  is,  doubtless, 
erythematous  in  character.  About  this  time,  further,  according  to 
Dr.  Hilton  Fagge,  an  eruption  of  scattered  points  and  spots  may  be 


MEASLES.  139 

seen  over  the  mucous  membrane  of  the  soft  palate.  Thomas,  of 
Leipzig,  also  says  that  indications  of  the  cutaneous  rash  may  some- 
times be  seen  on  the  face  during  this  stage,  in  the  form  of  minute; 
puncta,  around  which  the  characteristic  papules  afterwards  develop. 

3.  Stage  of  Eruption. — Towards  the  close  of  the  fourth  day — 
rarely  earlier,  very  rarely  later — the  appearance  of  the  true  rash  of 
measles  is  heralded  by  a  renewed  rise  of  temperature  and  an  exacer- 
bation of  all  the  symptoms  connected  with  the  mucous  membranes. 
In  many  cases  there  is  a  profuse  serous  diarrhoea ;  and  sometimes  the 
eruptions  from  the  bowels  become  glairy  and  bloody,  indicating  the 
presence  of  morbillous  colitis.  The  eruption  appears  on  the  face 
first,  next  on  the  back  of  the  wrists,  afterwards  on  the  trunk,  lastly 
on  the  limbs.  It  consists  of  small  red  specks,  slightly  elevated 
and  velvety  to  the  touch,  on  the  forehead  and  face,  closely  resem- 
bling flea-bites  (Sydenham  and  Hilton  Fagge).  It  is  to  be  remem- 
bered, however,  that  the  face  generally  escapes  the  infliction  of  flea- 
bites.  These  specks  become  grouped  in  crescentic  patches,  leaving 
interstices  of  skin  of  normal  colour.  The  rash,  therefore,  is 
in  general  discrete  rather  than  confluent,  although  in  some  cases  it 
is  really  confluent.  It  is  of  a  deep  rose  or  crimson  colour,  inclining 
to  purple  (Hilton  Fagge).  There  is  some  swelling  of  the  face 
during  this  stage.  On  the  trunk  and  limbs  the  papules  are  less 
prominent  than  on  the  face.  Sometimes  the  true  eruption  is  inter- 
spersed with  a  crop  of  miliary  vesicles  with  an  inflamed  red  base. 
Occasionally — to  use  Sydenham's  words — "  the  eruptions  turn  livid, 
and  then  black  ;  but  this  happens  only  in  grown  persons,  who  are 
irrecoverably  lost  upon  the  first  appearance  of  the  blackness,  unless 
they  be  immediately  relieved  by  bleeding  and  a  cooler  regimen." 
These  varieties  of  the  rash  give  rise  to  the  terms  Morbilli  Iceves, 
Morbilli  papulosi  (the  French  Rougeole  boutonneuse),  Morbilli  miliares, 
Morbilli  confluentes,  Morbilli  hcemon-hagici  (Mayr  and  Hebra).  During 
the  eruptive  stage  the  perspiration  has  a  peculiar  heavy  odour, 
which  Niemeyer  compared  to  the  smell  of  a  freshly  plucked  goose. 

The  eruption  reaches  its  fullest  development  in  thirty-six 
hours  from  the  time  of  its  first  appearance — that  is,  on  the  sixth 
day.     It  is  then  dusky,  and  the  skin  begins  to  look  rough  and 


140  MEASLES. 

dirty.  As  the  rash  comes  out,  the  coryzal  symptoms  increase, 
and  the  temperature  rises  to  its  fastigium  or  acme  of  104°  to  105°  F. 
on  the  evening  of  the  5th  day,  or  on  the  6th  day — the  fever  being 
most  intense  when  the  eruption  is  at  its  height.  In  this  behaviour 
of  the  temperature  in  the  Eruptive  Fever  of  measles  we  have  a 
diagnostic  of  the  first  importance  between  smallpox  and  this 
disease. 

There  is  an  old  tradition  that  a  sudden  fading  of  the  rash  in 
measles  is  an  ominous  sign ;  but  its  truth  is  disputed  by  Thomas  of 
Leipzig.  At  the  same  time  there  can  be  no  doubt  that  the  rash 
develops  badly  or  not  at  all  in  the  presence  of  a  complication.  This 
occurrence  is  to  be  distinguished  from  those  rare  instances  in  which 
we  have  measles  without  a  rash  (Morbilli  sine  morbillis). 

With  the  fading  of  the  rash,  defervescence  begins,  and  is  almost 
completed  within  48  hours,  being  so  rapid  and  sudden  as  to  be 
diagnostic  of  measles.  Here  we  have  another  marked  contrast 
between  the  behaviour  of  the  temperature  in  smallpox  and  in 
measles  respectively — apyrexia  in  measles  taking  the  place  of  the 
secondary  fever  in  smallpox.  The  rash  fades  after  the  sixth  day 
slowly  and  in  the  order  of  its  appearance,  leaving  yellowish  red 
stains,  which  may  persist  for  several  days.  In  the  early  stage  of  its 
subsidence  the  eruption  of  measles  exactly  resembles  a  profuse 
maculo-petechial  rash  in  typhus  fever,  which,  indeed,  is  often 
called  the  "  measly  rash  of  typhus."  The  morbillous  catarrh — 
both  respiratory  and  intestinal — frequently  persists  at  this  stage, 
and  a  nummular  expectoration  indicates  that  the  bronchioles  share 
in  the  affection.  Now  and  then  it  happens  that  the  catarrhal 
symptoms  of  measles  are  wanting,  or  nearly  so.  To  this  aberrant 
but  mild  form  of  the  disease  Dr.  Willan  gave  the  name  of  Morbilli 
sine  catarrho. 

4.  Stage  of  Desquamation. — This  commonly  begins  about  the 
eighth  day  and  ends  about  the  eighteenth  day,  counting  from  the 
first  symptoms.  The  skin  peels  off  in  small  bran-like  scales,  hence 
the  term  furfuraceous  desquamation  (Lat.  furfur,  scurf  or  bran). 
Trousseau  says  that  these  tiny  branny  flakes  are  seldom  seen,  because 
they  adhere  to  the  dress  if  the  patient  perspires,  and  in  this  opinion 


MEASLES.  141 

Hebra  concurs.  But  a  careful  search  will  hardly  fail  to  reveal  this 
branny  desquamation  taking  place  across  the  bridge  and  along  the 
sides  of  the  nose,  as  well  as  about  the  mouth  and  on  the  neck. 

In  uncomplicated  measles,  convalescence  may  be  said  to  be 
complete  on  the  eighteenth  day  from  the  earliest  symptoms. 

In  rare  cases  a  relapse  of  the  eruption. has  been  known  to  occur, 
associated  with  a  return  of  the  fever  movement  also.  In  these 
cases,  according  to  Thomas,  the  spots  appear  on  parts  of  the  skin 
previously  uninvaded  by  the  exanthem.  These  relapses  are  of  short 
duration.  Lewina  mentions  an  anomalous  course  of  measles  in  two 
boys.  The  rash  disappeared  suddenly,  without  causing  any  percep- 
tible injury  to  the  patients,  but  only  to  return  after  two  weeks.  In 
one  case,  the  renewed  attack  ran  a  normal  course  ;  in  the  other, 
this  occurred  only  after  a  second  equally  harmless  interruption  of 
several  days.  "  Such  a  course,"  says  Thomas,  "  is  perhaps  a  parallel 
one  to  many  of  those  relapses  appearing  after  the  first  eruption,  also 
to  Trojanowsky's  recurrent  form  of  measles." b 

a  Jahrbuck  filr  Kinderheilhunde.     Vol.  42,  page  95. 
b  See  Dorp.  med.  Zeitung.     1873. 


142 


CHAPTER  XIV. 

Measles  (continued). 

Classification — Complications — Temperature — Pathology — 
Diagnosis — Prognosis. 

Classification  of  Measles  :  Niemeyer's. — Benign  and  Malignant. — 
Benign  :  Morbilli  sine  catarrho  ;  Morbilli  sine  morbillis.  Malignant ;  Purpuric 
Measles  ;  Asthenic  or  Adynamic  Measles  ;  Complicated  Measles. — Causes  OF 
Complications  (Hebra).— Complications  of  the  stage  of  invasion :  Convulsions, 
spasmodic  catarrhal  laryngitis  (false-croup),  suffocative  catarrh,  epistaxis,  otitis, 
diarrhoea,  colitis  ;  of  the  stage  of  eruption  :  morbillous  diarrhoea,  capillary 
bronchitis,  pneumonia,  diphtheria  (true-croup);  of  the  stage  of  desquamation  : 
glandular  enlargements,  otitis,  cancrum  oris  (noma),  gangrene  of  the  vulva, 
acute  desquamative  nephritis,  acute  miliary  tuberculosis,  herpes,  eczema,  etc., 
pleuritis,  chronic  ophthalmia,  atrophic  keratitis. — Temperature  in  measles. — 
Pathology.  —  Diagnosis  :  from  epidemic  rose-rash,  scarlatina,  smallpox, 
Grisolle  sign,  varicella,  simple  rose-rashes,  typhus. — Prognosis. 

Classification  of  Measles. — Niemeyer  describes  three  varieties 
of  the  disease  under  the  headings— 1.  Morbilli  vulgar  es,  simplices, 
vel  erethici  ;a  2.  Inflammatory  or  synochal  Measles  ;  3.  Asthenic,  typhous, 
or  septic  Measles.  Another  convenient  arrangement  of  the  cases  is 
into  the  two  groups  of  benign  and  malignant.  In  the  former  are 
included  two  species — 1.  Morbilli  sine  catarrho  ;  and  2.  Morbilli  sine 
morbillis.  In  the  latter  we  have  three  species — 1.  Purpuric  Measles  ; 
2.  Asthenic  or  Adynamic  Measles  ;  and  3.   Complicated  Measles. 

According  to  Thomas  the  form  of  benign  measles  in  which  there 
is  rash,  but  no  catarrh  (Morbilli  sine  catarrho)  is  especially  apt  to 
occur  in  very  young  infants,  and  is  attended  with  little  or  no  fever. 
Probably  many  cases  of  Rotheln  were  formerly  classified  as  non- 
catarrhal  measles.  The  occurrence  of  measles  without  the  rash 
(Morbilli  sine  morbillis)  is  probably  a  rare  clinical  experience. 

Malignant  Measles. — 1.  Of  this  form  of  the  disease  the  purpuric 

variety  is  very  infrequent.  Trousseau  in  his  vast  expei'ience  met  with 

but  two  cases.     It  is  observed  chiefly  in  young  and  sickly  children 

"  Gk.  ipe6KTriK6s,  irritative,  or  provocative,  from  epedlfa,  to  rouse  to  anger,  to 
excite.     Hence,  rubefacient  (or  causing  redness). 


MEASLKS.  143 

(Hilton  Fagge).  The  rash  is  profuse  and  dark,  the  skin  is  dotted 
over  with  petechias  and  vibices,  while  blood  oozes  from  the  mucous 
membranes  in  all  parts  of  the  body.  Death  generally  takes  place 
in  a  few  days.  In  Willan  and  Bateman's  Atlas  of  Skin  Diseases  B 
will  be  found  an  illustration  of  the  appearances  presented  by  the 
skin  in  a  form  of  the  disease  which  Dr.  Willan  called  Rubeola  nigra. 
This,  however,  must  be  quite  different  from  Purpuric  Measles,  for 
he  says  the  dark  purple  or  black  colour  of  the  rash  continued  from 
the  eighth  day  for  ten  days  or  longer  "  without  materially  disturbing 
the  functions  of  the  patient."  Such  a  description  could  never  applv 
to  the  "  Black  Measles  "  of  the  older  writers — the  Morbilli  nigri,  vel 
petechiales — which  has  been  just  described.  The  ostensible  fre- 
quence of  this  form  long  ago  is,  according  to  Thomas,  to  be 
explained  in  part  "  by  the  preposterous  treatment  of  old  times," 
partly  by  the  fact  that  measles  and  scarlatina  were  confounded 
together  and  malignant  forms  of  scarlet  fever  were  described  as 
measles.  I  agree  with  Hilton  Fagge  also  that  no  doubt  cases  of 
hasmorrhagic  smallpox  were  sometimes  classed  as  "  Black  Measles." 

2.  In  asthenic  or  adynamic  measles,  the  symptoms  are  severe  and 
persistent — the  fever  is  intense  so  that  the  patient  is  soon  ex- 
hausted, the  pulse  becomes  rapid  and  feeble,  delirium  gives  place  to 
somnolence,  and  at  last  the  "  typhoid  "  or  "  ataxic  "  state  ensues  and 
terminates  too  often  in  early  death.  The  term  "  ataxic  state  "  is 
applied  to  a  group  of  symptoms  which  indicate  extreme  nervous 
prostration,  namely,  sleeplessness,  delirium,  small  rapid  pulse,  quick 
shallow  breathing,  agitation  and  restlessness,  tremors,  plucking  at 
Ihe  bedclothes,  dilatation  of  the  pupils,  and  finally  deepening  coma 
and  insensibility.     I  will  return  to  this  subject  later  on. 

3.  According  to  Hebra,  the  cause  of  complications  must  be 
sought  for — (a)  in  individual  peculiarities  of  the  patient,  (/3)  in 
the  conditions  under  which  he  lives,  and  (7)  in  the  special  charac- 
ters of  the  prevailing  epidemic — to  use  Sydenham's  classical  phrase, 
the  "  epidemic  constitution  "  of  the  time  or  place. 

"■Delineations  of  Cutaneous  Diseases.  London:  Longmans,  Hurst,  Eees, 
Orme,  and  Brown.     1817. 


144  SlEASLES. 

It  will  be  convenient  to  consider  the  complications  of  measles 
as  they  present  themselves  in  the  stages  of  onset  or  invasion,  of  the 
rash,  and  of  convalescence  respectively. 

Stage  of  Invasion. — Measles  is  not  uncommonly  ushered  in  by 
an  attack  of  convulsions  in  young  or  nervous  children.  Such  an 
attack  or  "  fit  "  is  simply  an  exaggerated  rigor  with  cerebral  pheno- 
mena. It  is  not  of  very  serious  import  unless  it  persists  for  over 
two  days.  Trousseau  mentions  a  very  remarkable  case  in  which 
the  tonic  stage  of  the  convulsive  fit  lasted  for  two  minutes  and  a 
half  and  death  occurred. 

The  mucous  membrane  of  the  larynx  is  often  the  seat  of  ulcerations 
and  erosions,  which  occasion  severe  laryngeal  symptoms,  constituting 
the  condition  known  as  "  false-croup,"  or  spasmodic  catarrhal 
laryngitis.  The  cough  is  dry  and  harsh,  frequent  and  spasmodic. 
The  voice  is  hoarse,  every  movement  of  the  larynx  is  painful,  and 
and  inspiration  is  laboured,  accompanied  with  wheezing,  whistling 
sounds  like  those  of  asthma.  At  times,  especially  after  a  fit  of 
coughing  or  when  drinking,  suffocative  spasms  and  a  painful  sense 
of  oppression  across  the  chest  occur  (Mertens  a). 

Suffocative  catarrh  may  occur  during  any  of  the  stages  of  measles. 
Its  symptoms  are :  high  fever,  oppression  of  the  chest,  dyspnoea, 
and  moist  cough.  Children,  as  a  rule,  do  not  spit  out,  but  swallow 
the  expectoration — hence  it  cannot  conveniently  be  examined ; 
but  in  adolescents  and  adults  the  sputa  consist  at  first  of  thin, 
limpid  mucus  ;  afterwards  they  become  copious  and  muco-purulent 
in  character,  occasionally  rusty  or  prune-juice,  if  the  so-called 
croupous  pneumonia  supervenes.  Three  stages  or  degrees  of 
bronchitis — the  most  common  and  the  most  perilous  of  the  com- 
plications of  measles — are  recognised :  ordinary  tracheo-bronchial 
catarrh,  capillary  bronchitis  or  bronchiolitis,  and  broncho-pneu- 
monia— also  called  catarrhal  pneumonia,  or  lobular  pneumonia. 
In  young  children  this  affection  is  dangerous  from  purely  mechanical 
causes — suffocation  being  brought  about  by  oedema  of  the  bronchial 
mucous  membrane  and  accumulation  of  secretion.  Of  the  three 
forms  of  bronchial  affection  just  described,  tracheo-bronchial 
a  Canstalt's  J ahresberkht.     1852.     IV.     Page  210. 


MEASLKS.  14-; 

catarrh  is  most  common  in  the  stage  of  invasion ;  the  other  and 
severer  forms  in  that  of  eruption. 

Epistaxis,  or  nose-bleeding,  may  be  so  severe  as  to  endanger 
life  or  permanently  injure  health. 

Otitis  is  hard  to  diagnosticate  in  an  infant,  but  cries  and  delirium 
from  pain  should  suggest  the  presence  of  ear-trouble,  and  sup- 
puration leading  to  otorrhoea  usually  solves  the  difficulty  in  3G 
or  48  hours. 

Diarrhoea  is  dangerous  if  continuous  to  the  time  when  the  rash 
is  due  to  appear,  if  the  rash  does  not  "  come  out "  well,  and  if  the 
eyes  look  sunken  with  dark  rings  around  their  lids.  The  intestinal 
morbillous  catarrh  often  attacks  the  colon,  causing  Colitis  with 
glairy,  bloody  stools,  and  tenesmus.  This  accident  usually  occurs  in 
the  eruptive  stage. 

Stage  of  Eruption. — In  this  stage,  in  addition  to  morbillous 
diarrhoea,  capillary  bronchitis  and  pneumonia  are  frequent  and 
most  dangerous  complications  of  measles.  Their  approach  is 
indicated  by,  perhaps,  an  attack  of  convulsions — a  most  fatal 
occurrence  in  this  stage  of  the  disease— by  persistently  high  tem- 
perature after  the  sixth  day,  and  by  early  and  rapid  fading  of  the 
rash.  Bronchitis  is  a  very  obstinate  complication,  running  on,  it 
may  be,  to  twenty  or  thirty  days  should  the  patient  survive  so  long. 
Diphtheria  of  the  pharynx  and  of  the  larynx,  membranous 
laryngitis,  or  true  croup,  is  another  dangerous,  though  rare  com- 
plication of  the  eruptive  stage.  The  diagnosis  is  based  on  the 
detection  of  false  membranes  and  the  presence  of  signs  of  laryngeal 
stenosis,  or  narrowing,  due  to  mechanical  obstruction. 

Stage  of  Desquamation. — During  this  stage  we  meet  with,  as 
sequela?  and  in  addition  to  broncho-pneumonia,  glandular  enlarge- 
ments in  the  neck  and  in  the  thorax  (bronchial  glands).  These 
may  go  on  to  suppuration  and  cicatrisation,  or  the  glands  may 
become  the  seat  of  tubercular  deposits  or  infiltrations. 

Otitis  in  this  stage  may  involve  the  middle  ear,  and  affect  the 
brain  and  dura  mater  through  the  mastoid  cells  ;  or  it  may  give 
rise  to  purulent  infection  by  inducing  septic  phlebitis  and  throm- 
bosis of  the  cerebral  sinuses.     Trousseau,  in  his  Clinical  Medicine, 

L 


146  MEASLES. 

reports  a  remarkable  case  in  point,  which  was  seen  in  consultation 
and  diagnosticated  by  Dr.  Peter.8, 

Cancrum  oris  or  noma,  and  gangrene  of  the  vulva,  may 
occur  in  delicate,  badly-fed  and  badly-clothed  children,  sometimes 
speedily  destroying  life,  but  in  non-fatal  cases  leaving  disfiguring 
losses  of  tissue. 

Acute  desquamative  nephritis  is  much  less  common  in  measles 
than  it  is  in  scarlatina. 

Acute  miliary  tuberculosis  often  supervenes  upon  an  attack  of 
measles,  the  tubercles  invading  specially  the  lungs  and  the 
membranes  of  the  brain. 

Herpes  and  eczema  often  follow  measles,  attacking  the  upper 
lip,  nasal  fossae,  posterior  nares,  and  Eustachian  tube. 

Pleuritis  was  observed  as  a  sequela  of  measles  by  the  late  Pro- 
fessor Fleetwood  Churchill,  of  Dublin,  and  by  Professor  Seidl. 

Chronic  ophthalmia  ("  Exanthematous  ophthalmia"  of  War- 
drop),  with  "  granular  lids "  and  distressing  photophobia,  and 
atrophic  or  secondary  keratitis,  must  be  included  among  the  many 
eye  affections  which  follow  measles. 

In  considering  the  subject  of  the  complications  and  sequelae  of 
this  disease,  it  should  never  be  forgotten  that  an  attack  of  measles 
often  sows  the  seed  of  even  a  fatal  constitutional  delicacy. 

Temperature. —  According  to  Wunderlich,  the  characteristic 
features  in  the  temperature  movement  in  measles  are  — 

1.  In  the  stage  of  incubation,  a  short  preliminary  fever  course 

in  the  form  of  an  ephemera,  in  which  the  thermometer 
may  mark  102*8°  to  103*6°.  This  is  followed  by  a  pause 
or  interval  of  several  days  quite  free  from  fever. 

2.  An  initial  or  prodromal  fever  occurring  in  the  stage  of  in- 

vasion, the  temperature  rising  from  the  time  of  the  first 
symptoms  to  102'4°,  and  even  104°,  on  the  evening  of  the 
first  day.  Next  day  a  decided  fall,  so  that  on  the  third 
day  the  temperature  is  either  normal  or  sub  febrile.     This 

a  Lectures  on  Clinical  Medicine  delivered  at  the  HStel  Dieu,  Paris.  New  Syd. 
Soc.  Translation.     1869.    Vol.  II.,  page  231. 


PlaUE. 

CHARTS   OF  TEMPERATURE  RANGES  IN  MEASLES. 


Mg. I- Simple,  Wcwks. 

Jig.  2.  -Measles. , ■''after, Scar/.ztiJiccJ 

Da,   «r     ., 

!>■*.■  ...    - 

jjjj 

Dayof   4-    5     6     7     a     9    10    11 

>h.:   ■  ■■, 

ra    13  14    15    is    17    is    :.'   ::•-  ::i    '■:'  ■■<    v  ?5  ."}  :v 

=  :EE=E  E  =  z:i:=;=zi:Fz::f  ;z:  =  z:;: 

W0-+- 

tt3. 

Iff 

_±±__ 

M  = 
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Ei±E 

-■hitEE-: 

-— 

Scar&x&'rca. 

^eojte 

iv'f/ 3-Meosles,  /after  Scarlatina..] 


Fig  J— Si. 


|jg£    7      3     9     10    11     IZ 

n 



wJE  —  Ei;:"" 

=:::z^=:^::: 

*==HH=!!ee= 

MEASLES.  147 

pyrexial  movement  may  easily  be  confounded  with  an 
ephemeral  fever. 

3.  The  true  eruptive  fever,  setting  in  shortly  before  the  rash  is 

due,  and  consisting  of  (a)  a  moderately  febrile  stage  which 
lasts  from  36  to  48  hours,  and  (/3)  the  stage  of  fastigium 
which  corresponds  in  point  of  time  with  the  fullest  develop- 
ment and  extension  of  the  exanthem,  and  lasts  from  one  and 
a-half  to  two  and  a-half  days. 

4.  Decided  defervescence  in  uncomplicated  cases  begins  according 

to  rule  in  the  night,  and  generally  runs  a  rapid  course,  being 
completed — after  one  or  two  evening  exacerbations — by  the 
eighth  or  ninth  day  of  the  attack. 

The  appended  charts  will  illustrate  the  behaviour  of  the  tempera- 
ture in  measles.     (See  Plate  II.) 

Pathology. — Among  the  pathological  changes  produced  by 
measles,  Mayr  and  Hebra  mention,  in  the  first  place,  a  catarrhal 
inflammation  of  the  mucous  membrane  of  the  respiratory  tract ; 
but  assuredly  the  intestinal  mucous  membrane  is  also  the  seat  of 
a  specific  catarrh. 

It  is  true  that  Thomas,  of  Leipzig,  while  stating  that,  as  a  rule, 
the  mucous  membranes  of  the  nose,  the  throat,  the  upper  air- 
passages,  and  the  conjunctivae  are  attacked,  and  often  much  sooner 
than  the  outer  skin,  cannot  admit  any  similarity  of  this  affection 
of  the  mucous  membranes  with  that  of  the  skin,  and  so  does  not 
recognise  the  perfect  justness  of  the  term  "  exanthem  of  the  mucous 
membranes." 

But  the  appearances  described  by  Thomas  himself,  by  Hilton 
Fagge,  and  by  others  in  connection  with  the  visible  mucous  mem- 
branes, as  well  as  the  catarrhal  symptoms,  justify  us  in  concluding 
that  the  mucous  membranes  are  really  the  seat  of  an  exanthem,  or, 
more  correctly,  an  enanthem — a  view  which  the  analogy  of  smallpox 
altogether  supports. 

The  nasal  mucus,  according  to  Mayr  and  Hebra,  is  at  first  trans- 
parent, afterwards  opaque;  its  reaction  is  always  alkaline,  never  acid. 

The  same  authorities  assert  that  the  efflorescence  consists 
essentially  in  the  pouring   out  of   exudation   around  the  mouths 


148  MEASLES. 

of  the  hair-sacs.  This  view  is  disputed  by  Thomas,  who  says  that, 
if  the  hair-follicles  specially  participated  in  the  inflammatory  process 
in  morbillous  dermatitis,  the  scalp  would  necessarily  be  the  proper 
focus  of  the  exanthem,  and  the  palms  of  the  hands  and  the  soles 
of  the  feet  would  remain  free — neither  of  which  is  the  case.  G. 
Simon  also,  in  1848,  found  no  change  in  the  hair-sacs,  sebaceous 
glands,  or  cutaneous  papillae,  but  described  the  epidermis  as  being 
still  in  immediate  contact  with  the  corium,  although  slightly  swollen 
at  those  points  where  papules  exist. 

Diagnosis. — The  recognition  of  measles  depends,  first  on  the 
exanthem ;  secondly,  upon  the  mucous  membrane  symptoms  and 
the  characters  of  the  fever  (the  behaviour  of  the  temperature) ; 
thirdly,  upon  a  consideration  of  the  existing  epidemic  and  the 
exposure  of  the  patient  to  the  virus  of  measles. 

Measles  must  be  distinguished  from — Rotheln,  or  Epidemic  Rose 
Rash  (Roseola) ;  Scarlet  Fever,  Variola,  Varicella,  simple  Roseolar 
Rashes,  and  Typhus  Fever. 

In  epidemic  rose  rash,  the  stage  of  invasion  is  only  1  to  3  days, 
the  pyrexia  is  much  less  than  in  measles,  the  catarrhal  symptoms 
are  slight,  and  the  rash  is  less  typical.  The  lymph-glands  also  are 
more  swollen  than  in  measles. 

In  scarlet  fever  there  is  a  short  invasion,  only  24  hours  ;  vomit- 
ing is  constantly  observed ;  catarrhal  symptoms  are  absent,  while 
there  is  early  and  severe  sore  throat  with  marked  swelling  of  the 
lymph-glands.  The  tongue  presents  the  appearance  known  as 
"  strawberry-tongue."  The  fever  runs  a  continuously  severe  course 
and  drops  gradually  by  lysis,  with  morning  remissions  and  evening 
exacerbations.  The  rash  is  commonly  confluent,  consisting  of 
bright  red  or  scarlet  points  with  a  diffuse  hyperasmic  blush.  The 
kidney  affection  of  scarlatina  is  wanting  in  measles. 

The  most  common  error  of  diagnosis  is  between  measles  and 
smallpox,  but  the  development  of  the  pustular  rash  of  smallpox 
sets  the  question  at  rest.  At  the  beginning,  too,  confluent  small- 
pox presents  an  eruption  on  the  second  day  compared  with  the 
fourth  or  fifth  day  in  measles.  The  papules  of  smallpox  are  hard  and 
shotty ;  those  of  measles  are  soft  and  velvety.  The  application  of 
the  test  called  the  "Grisolle  sign  "  is  also  to  be  remembered  (see  p.  98). 


MEASLES.  149 

Absence  of  catarrhal  symptoms,  a  short  invasion-stage,  its  slight 
pyrexia,  and  the  life-history  of  the  vesicles,  serve  to  distinguish 
varicella  from  measles. 

Simple  rose  rashes  are  distinguished  by  absence  of  fever  and 
of  catarrh,  and  by  their  inconstant  and  evanescent  nature. 

Typhus  in  children  may  be  mistaken  for  measles,  although  my 
experience  is  that  young  children  have  typhus  as  a  rule  lightly, 
with  only  a  scanty  rash  or  without  any  rash  at  all.  The  catarrh 
of  measles  is  wanting,  its  rash  is  brighter  than  that  of  typhus,  and 
does  not  pass  through  the  macular  and  petechial  stages  of  the 
typhus  eruption.  The  diagnosis  may  be  assisted,  as  Murchison 
says,  by  examining  other  members  of  the  same  family  who  may 
be  affected  at  the  same  time.  Measles  usually  attacks  children ; 
typhus  rarely  attacks  children  before  the  adult  members  of  a  family. 

Prognosis. — This  in  primary  and  uncomplicated  measles  is 
thoroughly  favourable,  death  from  the  severity  of  the  infection 
alone  being  extremely  rare  (Thomas.)  The  mortality  of  measles 
varies  greatly  from  time  to  time  according,  as  Sydenham  would  say, 
to  the  "  Epidemic  Constitution  "  of  the  time  and  place.  Sometimes 
only  2  or  3  per  cent,  of  the  patients  die ;  occasionally,  the  death- 
rate  reaches  the  alarming  figure  of  50  per  cent.  In  1845  and  1846 
Trousseau  says  he  lost  22  out  of  24  children  with  broncho-pneu- 
monia in  the  Necker  Hospital,  Paris.a  Measles  is  a  mild  disease  in 
sucklings  under  six  months  old ;  it  becomes  severe  at  the  first 
dentition,  and  is  sometimes  very  severe  in  adults.  In  pregnancy 
it  is  a  dangerous  malady.  It  is  most  fatal  among  persons  who  are 
ill-nourished,  rachitic,  or  tuberculous  (scrofulous.)  It  kills  from 
6,000  to  14,000  children  yearly  iu  England,  90'5  per  cent,  of  the 
victims  being  under  five  years  of  age. 

Unfavourable  symptoms  in  a  case  are:  great  weakness  and 
excitement  from  the  outset ;  a  hot,  dry  skin ;  a  hard  and  rapid 
pulse  ;  quick,  laboured  respiration  with  a  short  cough  ;  early  fading 
of  the  rash,  or  a  change  of  colour  in  it ;  or  a  persistent  (petechial) 
rash.  By  far  the  most  fatal  complication  of  measles  is  bronchitis 
in  its  severer  forms. 

a  Clinique  medicale  de  I'H&tel  Bieu  de  Paris.     1865.     Tome  L,  page  145. 


150 


CHAPTER  XV. 
The  Treatment  of  Measles. 

Prophylaxis  :  quarantine,  isolation,  hygienic  measures. — Curative  Treat- 
ment :  no  specific  for  measles — treatment  is  symptomatic  and  hygienic. 
Treatment  of  Complications  :  Malignant  Measles — cool  baths  (Dieulafoy). — 
Initial  convulsions,  false  and  true  croup,  epistaxis.  otitis,  diarrhoea,  ophthalmia, 
glandular  enlargements,  noma,  gangrene  of  the  vulva,  acute  tuberculosis. 

I.  Prophylaxis. — Owing  to  the  fact  that  measles  is  infectious 
from  the  outset,  and  that  the  first  case  in  a  household  may  readily 
be  mistaken  for  an  ordinary  cold,  the  attempt  to  stay  its  spread  by 
adopting  preventive  measures,  and  especially  isolation,  is  practically 
futile,  Hence  the  extreme  difficulty  of  arresting  an  outbreak  of 
this  disease  in  a  family  or  a  community. 

Should  an  individual  have  been  exposed  to  the  infection  of 
measles,  at  least  sixteen  days'  quarantine  will  be  necessary  before 
he  can  be  pronounced  safe.  A  patient,  again,  who  has  passed 
through  an  attack  of  measles,  should  not  be  declared  free  from 
infection  until  at  least  three,  and  preferably  four,  weeks  have 
elapsed  from  the  first  symptoms.  It  will  be  remembered  that  the 
stage  of  desquamation  generally  lasts  until  the  eighteenth  day. 

With  the  view  of  lessening  the  susceptibility  to  measles,  the 
greatest  attention  should  be  paid  to  the  sanitary  surroundings  of  a 
community. 

II.  Curative  Treatment. — Dr.  Hilton  Fagge  aptly  points  out 
that  "  the  general  plan  of  treatment  in  measles  and  in  scarlatina  is 
the  same,  for  in  neither  of  these  maladies  have  we  any  specific 
method  of  dealing  with  the  malady  itself." 

Bearing  in  mind  the  tendency  to  catarrh  of  the  respiratory  mucous 
membranes  which  exists  in  measles,  a  mild,  equable  atmosphere  is 
essential  (60°  to  65°  F.).  In  winter  and  spring  a  steam  kettle  should 
play  in  the  sick  room,  at  all  events  at  night.  Ventilation  must  be 
effected  with  caution,  all  draughts  or  undue  lowering  of  temperature 


MEASLES.  151 

being  carefully  avoided.     Children  should  be  closely  watched  at 
night  lest  in  their  feverish  restlessness  the  bed-clothes  should  be 
thrown  off,  and  they  in  consequence  should  be  exposed  to  cold. 
The  hands  and  face  should  be  washed  daily.     The  patients  should 
be  allowed  to  drink  water  freely,  or  bland  mucilaginous  drinks  like 
linseed  tea,  barley  water,  and  toast-water.     The  diet  should  consist 
of  milk  and  animal  broths,  the  latter  to  be  thickened  with  rice, 
arrowroot,  or  gelatine  in  cases  of  diarrhoea.     On  the  other  hand, 
in  constipation  (which,  in  measles,  is  rare),  oranges,  stewed  prunes, 
baked  apples,  and  so  on,  may  be  given.      During   the    stage    of 
desquamation,  the  patient  should  be  kept  as  far  as  possible  in  bed. 
Warm  baths  are  specially  useful,  as  they  relieve  troublesome  itch- 
ing, remove  the  debris  from  sweat  and  desquamation,  and  generally 
soothe   the  patient.     The  surface  of  the  skin  may  afterwards  be 
oiled  with  advantage — liniment  of  camphor,  a  weak  carbolised  oil 
or  soft  paraffin,  or  "  hazeline  cream,"  being  used  for  the  purpose. 
All  exposure  to  cold  should  be  avoided  until  the  catarrhal  symptoms 
have  entirely  disappeared.     In  convalescence,  fresh  air,  driving  in 
the  open  country,  and  change  of  air  to  the  seaside  or  some  sheltered 
inland  health-resort,  are  most  desirable. 

Among  drugs  suitable  for  administration  to  convalescents  from 
measles,  mention  may  be  made  of  quinine,  saccharated  carbonate  of 
iron,  cod-liver  oil  with  saccharated  solution  of  lime,  and  chloride  of 
calcium. 

The  skill  of  the  physician  is  often  taxed  to  the  uttermost  in  the 
treatment  of  the  complications  of  measles. 

In  malignant  measles,  Dieulaf oy,  of  Paris,  recommends  a  a  bath 
at  26°  C.  (78-8°  F.)  for  twelve  minutes,  with  cold  affusion  on  the 
head.  These  measures  will  reduce  temperature  (102'9°)  and  the 
respirations  (70).  A  second  bath  at  five  o'clock  in  the  afternoon ; 
a  third  at  9  p.m.,  a  fourth  at  2  a.m.,  a  fifth  at  5  a.m.  These  will 
probably  be  followed  by  marked  improvement,  reduction  of  tem- 
perature, and  sleep.     A  sixth  bath,  at  6  p.m. 

The  cold  bath  re-establishes   the  secretion  of  urine,  the  skin 

ft  La  Pratique  Joumaliere  des  Hdpitaux  de  Paris.  Par  le  Professeur  Paul 
Lefort.     Paris     J.  B.  Bailliere  et  Fils.     1891.    Page  312. 


1 52  MEASLES. 

becomes  soft,  and  temperature  falls  to  101*1° 'F.     As  regards  the 
rash,  it  becomes  pale  but  runs  its  course. 

In  a  case  of  initial  convulsions  Trousseau's  advice  is  excellent — 
"Wait — avoid  boisterous  practice."  Find  out  if  the  patient  is 
subject  to  fits.  If  the  attack  persists,  compression  of  the  carotids 
may  be  practised  in  the  way  recommended  by  Trousseau — namely, 
by  pressing  with  the  thumb  on  the  common  carotid  opposite  to 
the  affected  side  of  the  body,  or  alternately  on  each  side  of  the 
neck,  keeping  up  the  pressure  for  some  fifteen  minutes, 

In  false  and  true  croup  the  patient  should  be  placed  in  a  croup- 
tent,  and  a  simple  plan  recommended  by  Graves  and  heartily 
approved  by  Trousseau  should  be  followed.  This  is  an  application 
during  twenty  or  twenty-five  minutes  of  relays  of  sponges  soaked  in 
hot  water  to  the  neck  and  throat. 

These  same  measures  will  prove  useful  in  suffocative  catarrh 
also,  in  which  hot  poultices  and  the  application  of  a  cuirass  of 
cotton  wool  or  French  wadding  to  the  chest  wall  are  very  effective. 
Trousseau  recommends  stinging  the  chest  with  nettles  (urtication) 
as  an  effectual  means  of  producing  counter-irritation. 

In  epistaxis,  the  application  of  ice  to  the  forehead  and  that  of  a 
cold  key  to  the  nape  of  the  neck  are  household  remedies  not  to  be 
despised.  Either  iced  water  or  very  hot  water  may  also  be  injected 
into  the  nostrils.  In  extreme  cases  it  becomes  necessary  to  plug 
the  posterior  nares. 

In  otitis,  the  external  meatus  should  be  gently  syringed,  or  a 
chamomile  flower  soaked  in  warm  almond  or  olive  oil,  or  in  vaseline, 
may  be  inserted  every  few  hours,  taking  care  to  cleanse  the  passage 
each  time.  Sometimes  the  application  of  a  single  leech  to  the 
mastoid  process  allays  pain  and  affords  immediate  relief. 

While  diarrhoea  is  often  checked  by  good  nursing  and  suitable 
dieting,  it  may  be  necessary,  as  recommended  by  Trousseau,  to 
give  minute  doses  of  opium  in  lime-water  (one-thirtieth  of  a  grain 
in  24  hours),  or  to  administer  albuminous  enemata,  if  colitis  occurs. 
Alterative  doses  of  perchloride  of  mercury  may  also  be  of  use. 
Dr.  Charles  West  recommends  decoction  of  logwood  with  white 
sugar  and  port-wine.     This  mixture  stains  linen  or  cotton  fabrics. 


MEASLES 


153 


For  ophthalmia,  fomentations  with  strained  decoction  of  poppies 
or  infusion  of  chamomile,  or  both,  or  with  cold  tea — which  contains 
tannin — often  give  relief.  When  a  sequel  of  measles,  ophthalmia 
requires  constitutional  treatment — iron  and  quinine,  cod-liver  oil, 
and  wine  or  eggflip. 

Glandular  enlargements  are  best  combated  by  a  generous, 
wholesome  diet,  with  milk,  cod  liver  oil,  iron,  iodide  of  iron,  quinine, 
chloride  of  calcium,  and  arsenic.  Change  of  air  is  especially  desir- 
able in  the  management  of  this  troublesome  sequela. 

Fresh  air  and  perfect  cleanliness  are  the  best  preventives  of 
noma,  gangrene  of  the  vulva,  and  such  like  complications.  The 
patient's  strength  must  be  supported  by  nutritious  food  and  wine. 
Caustics  may  be  used  in  certain  cases — namely,  hydrochloric  acid, 
nitrate  of  silver,  sulphate  of  copper,  or  the  actual  cautery. 

The   prevention  of  acute  tuberculosis  may  be  attempted  by 
change  of   air,  wholesome   surroundings,   a   nutritious  diet  with 
goat's  milk  and   koumiss  (mares'  milk  fermented),   syrup  of  the 
chloride  of  calcium  in  milk,  cod  liver  oil,  syrup  of  the  iodide  of 
iron,  compound  syrup  of  the  hypophosphites  or  of  the  phosphates, 
and  syrup  of  the  lacto-phosphate  of  lime.     A  favourite  combination 
with  me  is  embodied  in  the  following  prescription : — 
IL  Liquor.  Calcii  Chloridi,  3vj ; 
Acid.  Hydrochloric,  dil.,  3j  ; 
Liquor.  Strychninas  Hydrochlor.,  3j  ; 
Acid.  Hydrocyanic,  dil.,  5ss ; 
Liquor.  Arsenic.  Hydrochlorici,  33s ; 
Aquae  Chloroformi,  ad  gviij. 
M.  fiat.     Mistura. 
The  dose  of  this  mixture  for  an  adult  is  a  tablespoonful  by  mea- 
sure in  water  twice  or  thrice  daily  after  food.     A  child  aged  10  or 
12  years  may  take  half  this  dose. 


154 


CHAPTER  XVI. 

SCAELATINA,    OR    SCARLET    FEVER. 

Nomenclature. —Definition. — etiology  (historical  sketch). — Area  of  Diffu- 
sion.— Epidemic  and  sporadic  outbreaks  — Rate  of  Mortality  most  variable. — 
Pkedisposing  Causes  :  Climatic  influences  ;  season. — Exciting  Cause  :  Spe- 
cific poison — "Contagium  Vivum." — Professor  Klein's  Researches:  Streptococcus 
scarlatina. — Hendon  Cow  Disease. — Clinical  History  :  Scarlatina  simplex, 
anginosa,  and  maligna. — Varieties  of  Scarlatina  simplex. — Stages  of  Incuba- 
tion, Invasion,  Eruption,  Desquamation. — Prominent  Symptoms  :  Vomiting, 
sore-throat,  tache  scarlatinale,  "strawberry-tongue,"  albuminuria. 

Nomenclature. — "  Febris  scarlatina  "  (Ital.  Scarlatto,  scarlet)  was 
the  name  by  which  Sydenham  (1675)  and  afterwards  Withering 
(1778)  designated  this  disease.  Hence  the  synonyms  "Scarlatina" 
(Boissier  de  Sauvages,  Vogel,  and  Cullen)  and  "  Scarlet  Fever." 
It  had  been  described  as  far  back  as  1556  by  Ingrassias,  of  Palermo, 
under  the  name  "  Rosalia."  The  equivalents  are : — Latin,  Febris 
Rubra  (Heberden).  Germ.  Scharlachfieber,  or,  shortly,  Scharlach. 
Fr.  Fievre  rouge,  Scarlatine.  Ital.  Scarlattina,  Febbre  rossa.  Span. 
Escarlatina.  Danish  and  Norwegian,  Skarlagensfeber.  Swedish, 
Skarlakansfeber.     Dutch,  Scharlakenkoorts. 

Morton,  a  contemporary  of  Sydenham,  described  the  disease  as 
Morbilli  confluentes,  confounding  it  with  measles.  Another  name 
was  Morbilli  ignei,  that  is,  "  Fiery  Measles." 

Definition. — An  acute  specific  infectious  fever,  characterised  by 
a  sudden  onset  with  vomiting,  rigors,  and  prostration ;  early  and 
persistent  sore  throat,  deep  injection  of  the  mucous  membranes  of 
the  throat,  which  are  swollen  and  inflamed;  very  rapid  pulse-rate 
and  high  fever ;  and  especially  by  the  appearance  upon  the  skin 
after  a  few  hours  of  a  minutely  punctiform  scarlet  rash,  which  is 
most  intense  on  the  third  day,  and  afterwards  fades  gradually,  to 
be  succeeded  by  profuse  desquamation  of  the  cuticle  in  both  small 
and  large  flakes.  A  specific  nephritis  is  a  not  uncommon  complica- 
tion or  sequela.  Three  varieties  of  the  disease  are  recognised — 
namely,  simple,  anginose,  and  malignant  scarlatina. 

JEtiology. — The  origin  and  native  habitat  of  scarlet  fever  are 


SCARLATINA.  1").") 

quite  unknown.  By  far  its  largest  area  of  distribution  is  on  Euro- 
pean soil  (Hirsch).  In  Germany,  France,  the  British  Islands,  Scan- 
dinavia, and  Russia,  it  is  one  of  the  chief  factors  in  the  statistics  of 
sickness  and  mortality.  Up  to  the  present  it  has  a  very  scanty 
diffusion  in  Africa  and  Asia.  It  occurs  but  rarely  in  India,  is 
said  to  be  unknown  in  Japan,  and  assumes  generally  a  mild  type 
in  Australia,  Tasmania,  and  New  Zealand,  in  which  countries 
it  first  broke  out  in  the  beginning  of  1848.  The  first  appearance 
of  scarlet  fever  on  the  soil  of  North  America  dates  from  1735, 
when  it  broke  out  in  Kingston,  Massachusetts,  thence  spreading  to 
Boston  and  other  places  near,  and  finally  overrunning  the  whole  of 
the  New  England  States  in  the  course  of  the  next  few  years.* 
Nearly  a  century  elapsed  before  scarlet  fever  began,  about  1830,  to 
be  generally  diffused  over  South  America. 

The  area  of  diffusion  of  scarlet  fever  is  much  smaller  than  that 
of  smallpox  or  of  measles.  Its  epidemics  arise  at  long  intervals — 
ten  or  twenty  years  or  more  often  intervening  between  two  succes- 
sive outbreaks  at  a  given  place.  Its  epidemics  are,  however,  of 
protracted  duration ;  and  sporadic  outbreaks  arise  from  time  to 
time  in  the  intervals. 

Scarlatina  displays  extreme  variation  in  its  intensity — the  rate 
of  mortality  being  almost  nil,  or  only  from  3  to  5  per  cent,  of  those 
attacked,  in  some  epidemics;  but  in  others  rising  to  30  per  cent,  or 
upwards.  No  more  striking  proof  of  this  can  be  adduced  than  the 
words  in  which  Sydenham  described  scarlet  fever — "Hoc  morbi 
nomen,  vix  enim  altivs  assurgit."  According  to  Graves  b — the  his- 
torian of  the  disease  in  Ireland— in  the  months  of  September,  October, 
November,  and  December  of  the  year  1801,  scarlet  fever  "com- 
mitted great  ravages  in  Dublin,  and  continued  its  destructive 
progress  during  the  spring  of  1802.  It  ceased  in  summer,  but 
returned  at  intervals  during  the  years  1803-4,  when  the  disease 
changed  its  character,  and  although  scarlatina  epidemics  recurred 

a  The  Practical  History  of  a  New  Epidemical  Eruptive  Miliary  Fever.  By 
Dr.  Douglas.  Boston  :  1736.  Reprinted  in  The  New  England  Journal  of 
Medicine,  January  1825.     P.  1. 

b  A  System  of  Clinical  Medicine.  By  R.  J.  Graves.  Dublin  :  1843.  P.  493. 
Also  Clinical  Lectures  on  the  Practice  of  Medicine.  By  the  late  R.  J.  Graves. 
Dublin  :  Fannin  &  Co.     1864.     Pages  230,  et  seg. 


156  SCARLATINA. 

very  frequently  during  the  next  'twenty-seven  years,  yet  it  was 
always  in  the  simple  or  mild  form."  In  1834-35  another  destruc- 
tive epidemic  raged  in  Dublin,  and  so  to  the  present  day  outbreaks 
alternately  benign  and  malignant  have  been  observed,  according  as 
the  "  Epidemic  Constitution  "  varied,  as  Sydenham  would  say. 

Predisposing  Causes. — Climatic  Influences  do  not  play  a  pro- 
minent part  in  determining  the  geographical  distribution  of  the 
disease,  for  although  the  tropical  and  sub-tropical  regions  of  Asia 
and  Africa  have  so  far  almost  entirely  escaped  scarlet  fever,  yet  it 
has  often  prevailed  epidemically  in  the  tropical  countries  of  South 
America;  and,  on  the  other  hand,  in  certain  cold  or  temperate 
climates  scarlet  fever  is  among  the  rarest  of  diseases. 

There  is,  however,  evidence  that  season  does  influence  its  preva- 
lence. " Scarlatina"  observes  the  Registrar-General  of  England,4 
"  discovers  a  uniform,  well-marked  tendency  to  increase  in  the  last 
six  months,  and  attain  its  maximum  in  the  December  quarter,  the 
earlier  half  of  the  following  year  witnessing  a  decrease."  In 
Dublin,  also,  the  disease  is  almost  invariably  most  prevalent  and 
fatal  in  the  fourth  quarter  of  the  year. 

From  an  analysis  of  the  weekly  death-rate  from  scarlatina  in 

Dublin  it  would  seem  that  this  fever  shows  a  tendency  to  increase 

when  the  mean  temperature  rises  much  above  50°,  while  a  fall  of 

mean  temperature  below  this  point  in  autumn  checks  the  further 

rise  of  the  mortality.15     In  this  city,  scarlet  fever  is  most  fatal  in 

the  forty-sixth  week  of  the  year  (middle  of  November)  and  least 

fatal  in  the  twenty-fourth  week  (middle  of  June).     Dr.  Edward 

Ballard    draws    inferences   which   confirm   these    results.0      The 

"  Annual   Summary  of   Births,  Deaths,  and  Causes  of   Deaths," 

of  the  Registrar-General  of  England,  for  1890,  is  illustrated  by 

the  annexed  Diagram  (3.),  showing  the  weekly  mortality  curve  for 

scarlet  fever  in  London  on  an  average  of  30  years  (1861-1890). 

The  curve  consists  of  a  single  wave,  which  rises  to  its  crest  (60 

per  cent,  above  the  mean  line,  which  represents  an  average  weekly 

number  of  44  deaths)  in  October  and  November,  while  the  trough 

a  Twenty-eighth  Annual  Report  of  Births,  Deaths,  and  Marriages.     Page  38. 

b  Manual  of  Public  Health  for  Ireland.     1875.     Pages  303  and  304. 

c  Eleventh  Report  of  Med.  Officer  of  Privy  Council.    1868.    No.  3.     Pp.  54-62. 


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SCARLATINA.  lo7 

extends  from  February  to  August.  It  is  a  suggestive  fact  that 
the  corresponding  curves  for  diphtheria  and  enteric  (or  typhoid) 
fever  are  also  single  wave  curves,  closely  resembling  each  other 
and  that  of  scarlatina  in  rising  to  a  crest  in  October  and  Novem- 
ber, and  showing  a  trough  from  February  to  August. 

As  to  the  conditions  which  cause  scarlatinal  epidemics  to  assume 
a  good  or  bad  type,  Hirsch  emphatically  asserts  that  "  we  are  com- 
pletely in  the  dark." 

Traumatism  should  be  mentioned  among  the  predisposing  causes 
of  scarlatina.  When  the  disease  is  conveyed  through  the  infection 
of  a  wound — the  result  of  injury,  or  of  an  operation — it  is  called 
"Surgical  Scarlatina."  Trelata  in  France,  Hoffa  in  Germany, 
and  other  authoi*s,  have  drawn  attention  to  this  mode  of  origin  of 
scarlatina. 

Exciting  Cause. — The  specific  character  of  the  poison  of  scarlet 
fever  is  unquestionable,  and  all  analogy  points  to  its  organic  nature. 
The  exciting  cause  of  the  disease,  then,  is  almost  certainly  a  micro- 
organism, while  its  most  powerful  predisposing  cause  is  age — the 
susceptibility  to  the  disease  diminishes  quickly  after  the  tenth  year 
of  life.     It  is  not  well  marked  in  infants  under  six  months  old. 

The  contagium  vivum  is  singularly  retentive  of  life  and  most 
active.  Hence  isolation  of  the  sick  and  convalescent  is  rendered 
imperative.  The  virus  may  be  conveyed  by  fomites  or  dress  and 
other  articles,  such  as  bedding,  letters,  furniture,  carpets,  and  such 
like  ;  it  may  also  be  inhaled,  swallowed  in  water  or  milk,  or  con- 
veyed by  means  of  domestic  animals  such  as  cats  and  dogs.  Scarlet 
fever  may  be  inoculated  by  means  of  the  blood,  the  epidermic  scales, 
and  the  serum  from  cutaneous  vesicles.  The  urine  also  is  believed 
to  be  infective. 

An  epidemic  of  scarlatina  in  St.  Giles  and  St.  Pancras,  London,  in 

1882,   was   investigated   by   Mr.  Power,   Inspector   of    the   Local 

Government  Board  for  England,  with  the  result  of  suggesting  that 

the  disease  might  be  connected  with  a  disorder  in  milch  cows.b    A 

similar  outbreak  in  Marylebone  District,  in  1885,  was  clearly  traced 

to  the  use  of  milk  obtained  from  milch  cows  on  a  certain  farm  at 

a  Le  Progrfa  Medical,  Septembre  14,  1878.  [Also  see  below  under  "Acci- 
dental Rashes  in  Enteric  Fever."] 

b  Fifteenth  Annual  Report  of  the  Local  Government  Board,  1885-86. 


1 58  SCARLATINA. 

Hendon.a  These  cows  suffered  from  an  eruptive  disease  of  the 
udder  and  teats — a  condition  first  introduced  there  in  November, 
1885,  by  some  cows  newly  arrived  from  Derbyshire.  From  the 
diseased  tissues  of  man  and  cow  alike  a  special  streptococcus 
{Streptococcus  scarlatina)  was  separated  by  Professor  Klein.  This 
micro-organism  grows  on  gelatin  in  opaque  white  colonies,  and 
it  does  not  liquefy  the  gelatin.  It  is  slower  of  growth  than  most 
micrococci.  After  several  weeks  it  has  a  fairly  distinct  but 
slightly  irregular  and  crenate  outline,  here  and  there  beset  with  dark 
knobs  or  linear  processes.  When  grown  in  milk  it  coagulates  the 
milk.  Some  of  the  elements  may  be  observed  as  diplococci  or  as 
short  chains.  Cultivated  in  broth  it  forms  long  and  exquisite  chains. 
Subcultures  of  these  micrococci  have  the  property,  when  inoculated 
into  calves,  of  producing  in  them  every  manifestation  of  the  "Hendon 
disease,"  except  sores  on  the  teats  and  udders.  The  subcultures 
produce  in  rodents  a  disease  pathologically  similar  to  cow-scarla- 
tina and  human  scarlatina.  Calves  fed  on  subcultures  obtained 
from  human  scarlatina  contract  the  Hendon  disease.  In  the  Mary- 
lebone  epidemic  it  was  proved  that  children  fed  on  milk  from  cows 
with  the  Hendon  disease  contracted  scarlatina.  These  facts,  in 
the  opinion  of  Dr.  Buchanan,  Medical  Officer  of  the  English  Local 
Government  Board,  form  a  mass  of  evidence  that  the  Hendon 
disease  in  cows  is  a  form  of  the  very  disease  which  we  call  scarla- 
tina when  it  occurs  in  man.     This  view  awaits  final  confirmation. 

Prior  to  Klein's  investigations,  micrococci  had  been  described  by 
Coze  and  Feltz  b  as  being  present  in  the  blood  of  patients  suffering 
from  scarlatina ;  and  Pohl-Pincus  °  detected  them  in  the  scales 
of  the  desquamating  epidermis  and  in  the  discharges  and  ulcerated 
tissue  of  the  throat.  These  micrococci  form  small  colonies,  and 
stain  violet  with  a  saturated  solution  of  methyl  violet.  Their 
diameter  is  very  small — only  about  0*0005  mm.d 

Clinical  History. — Cases  of  scarlatina  are  arranged  under  three 
headings,  namely — 

a Seventeenth  Annual  Report  of  the  Local  Government  Board,  1887-88. 

b  Maladies  /nfectieuses.     1872 

c  Centralblatt  fur  die  med.  Wissenschaften.     No.  36.     1883. 

6  Micro-organisms  and  Disease.    By  E.  Klein,  M.D.,  F.R.S.    1886.    Page  78. 


SCARLATINA.  159 

1.  Scarlatina  simplex,  or  mild  scarlet  fever,  in  which  the  disease 
runs  its  course  without  complications  or  untoward  sequelae,  termina- 
ting in  an  uninterrupted  convalescence. 

2.  Scarlatina  anginosa  (Lat.  ango,  I  strangle;  Gk.  arjyw — 
hence,  angina,  quinsy;  Gk.  dy^ovr],  a  throttling  or  strangling),  in 
which  the  affection  of  the  throat  is  severe  and  the  cervical  glands 
are  sharply  engaged. 

3.  Scar  atina  maligna,  in  which  extreme  nervous  prostration, 
with  its  attendant  ataxic  or  "typhoid"  symptoms,  is  the  most 
striking  and  ominous  phenomenon. 

Of  simple  scarlet  fever  certain  varieties  have  been  described— as 
Scarlatine  fruste,  Defaced  or  Latent,  Rudimentary  or  Abortive  Scarlet 
fever,  Scarlatina  sine  exanthemate  or  Scarlatina  sine  scarlatinis,  and 
Scarlatina  faucium. 

We  will  now  consider  the  disease  as  it  passes  through  its  various 
stages  or  periods. 

I.  Stage  of  Incubation.— This  period  is  very  short,  probably 
never  extending  beyond  a  week  and  rarely  lasting  so  long.  It  may 
be  only  twenty-four  hours,  but  on  the  average  it  varies  from  three 
to  five  days.  In  1861  Trousseau  declared  that  neither  in  measles 
nor  in  scarlet  fever  could  the  duration  of  the  latent  period  "  be 
rigorously  determined  in  the  present  state  of  our  knowledge,"  while 
still  later  Obermeier  gave  it  as  his  opinion  that  the  incubation 
period  of  scarlatina  was  unknown.  Dr.  Charles  Murchison,a  Con- 
sulting Physician  to  the  London  Fever  Hospital,  collected  75  cases 
of  scarlet  fever,  having  any  bearing  on  the  question,  which  had 
either  come  under  his  own  observation  or  been  communicated  to  him 
in  the  twenty  years  ending  with  1878.  Of  the  total  75  cases,  in  not 
one  did  the  incubation  period  exceed  six  days  ;  in  73  cases  it 
could  not  have  exceeded  five  days ;  in  54  cases  it  could  not  have 
exceeded  four  days ;  in  20  cases  it  could  not  have  exceeded  three 
days  ;  in  1 6  cases  it  could  not  have  exceeded  two  days ;  and  in  3 
cases  it  could  not  have  exceeded  twenty-four  hours.     It  also  appears 

a  Observations  on  the  Period  of  Incubation  of  Scarlet  Fever,  and  of  some  other 
Diseases.  Clinical  Society's  Transactions.  Vol.  XI.,  page  238.  1878.  Cf. 
Braithwaite 's  Retrospect  of  Medicine.     Vol.  LXXIX,,  pages  1-5.     1879. 


1 60  SCARLATINA. 

that  the  longest  period  of  incubation  made  out  in  any  of  the  cases 
was  four  and  a  half  days  ;  and  that  in  only  two  of  the  cases  was 
it  certainly  as  long  as  four  days. 

Murchison's  observations  and  study  of  the  incubation  period  of 
scarlet  fever  led  him  to  the  following  conclusions :  — 

1.  The  duration  of  the  incubation  stage  may  be  only  a  few  hours. 

2.  Probably  in  a  large  proportion  of  cases  it  does  not  exceed 

forty-eight  hours. 

3.  It  very  rarely  exceeds  seven  days. 

4.  Consequently,  a  person  who  has  been  exposed  to  scarlet-fever, 

and  does  not  sicken  after  a  week's  quarantine,  may  be 
pronounced  safe. 

Some  of  the  following  cases  occurred  in  the  practice  of  my  father, 
Dr.  William  Daniel  Moore,  some  in  my  own  practice. 

On  November  2,  1848,  a  gentleman,  aged  twenty,  went  down  to 
the  County  Wexford  from  Dublin  three  weeks  after  the  disappear- 
ance of  the  rash  of  scarlet  fever.  On  his  arrival  the  same  day  he 
saw  two  sisters,  both  of  whom  took  to  bed  with  scarlet  fever  on 
November  8 — that  is,  in  six  days — incubation  =  five  days. 

A  boy  aged  eight,  sickened  with  scarlet  fever  on  January  12, 
1851.  His  sister  took  ill  on  the  17th,  and  five  days  later  another 
sister  sickened. 

Two  girls,  cousins,  slept  in  the  same  bed  on  April  5  and  6,  1855. 
One  of  them  complained  of  sore  throat  on  the  night  of  April  5,  and 
showed  the  rash  of  scarlatina  on  the  morning  of  the  7th.  The 
other  sickened  on  April  10th — that  is,  on  the  fourth  day. 

Of  two  sisters,  one  took  ill  on  December  27,  1871,  and  was 
at  once  isolated.  The  other  remained  under  the  same  roof,  but 
without  seeing  her  sister  until  they  met  by  accident  on  February  4, 
1872.     She  sickened  with  scarlet  fever  seven  days  later,  on  Feb.  11. 

A  lad,  George  G.,  aged  fourteen,  complained  of  pain  in  his  eyes 
on  Saturday,  January  5,  1878.  Next  day  he  sneezed  a  little.  On 
Monday  and  Tuesday  he  had  slight  headache.  On  Wednesday  he  Was 
admitted  to  the  Epidemic  Ward  of  the  Meath  Hospital  because  of 
a  rose-rash  on  his  face.  He  perspired  a  good  deal  and  felt  thirsty. 
His  temperature  was  100-8°,  pulse  96,  and  respirations  24.     On 


FlateM. 

CHARTS  OF  TEMPERATURE  RANGES  IN  SCARLATINA. 


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Figt  6.  —  S.  McUzgtrvcis 


SCARLATINA.  10  L 

examination  he  was  ascertained  to  have  had  measles  three  or  four 
years  previously  in  the  County  Carlow.  The  case,  therefore,  w;ib 
regarded  as  one  of  Rotheln.  On  January  14,  a  bad  case  of  scarla- 
tina was  placed  in  the  next  bed  to  that  occupied  by  George  G.,  and 
between  him  and  the  door  of  the  ward.  On  January  20,  he  was 
seized  with  sore  throat  and  vomiting,  and  next  day  the  rash  of 
scarlatina  came  out.  The  clinical  chart  of  this  case  will  be  found  in 
Plate  III.  (Fig-  I.)  The  incubation  period  here  coul  I  not  have 
exceeded  six  or  seven  days. 

This  stage  of  latency  may  be  unattended  by  symptom3,  or 
towards  its  close  there  may  be  slight  headache,  malaise,  lassitude, 
and  loss  of  appetite. 

II.  Stage  of  Invasion. — Like  the  stage  of  incubation,  this  period 
may  be  of  very  short  duration — most  commonly  only  twenty-four 
hours.  Sometimes  it  is  still  shorter,  or  very  rarely  it  may  extend 
to  several  days,  as  in  a  case  reported  by  Trousseau,  in  which  rebel- 
lions cerebral  symptoms  persisted  for  eight  days  and  then  suddenly 
subsided  on  the  appearance  of  sore  throat  and  the  rash  of  scarlet 
fever.  But  such  a  case  is  altogether  exceptional,  and  Dr.  Hilton 
Fagge  considered  that  a  question  might  fairly  be  raised  as  to  its 
original  nature.  This  pre-eruptive,  prodromal,  or  initial  stage  is 
shorter  in  scarlatina  than  in  any  other  fever. 

The  onset  of  the  malady  is  abrupt.  In  children,  the  earliest 
symptoms  are  usually  vomiting  and  diarrhoea,  rigors,  or  a  convul- 
sive seizure.  According  to  Trousseau,  the  occurrence  of  convul- 
sions during  the  first  or  second  day  is  always  a  sign  of  danger, 
whereas  in  other  exanthemata  it  is  not  of  evil  omen  (Hilton  Fagge). 
In  adults,  sore  throat  is  generally  the  first  symptom  :  it  is  accom- 
panied by  chilliness  or  rigors,  headache,  malaise,  and  prostration. 
Meanwhile  both  pulse  and  temperature  rise  quickly.  Even  on  the 
evening  of  the  first  day,  a  child's  pulse  may  range  between  140 
and  160,  his  temperature  may  rise  to  103°,  104°,  or  even  105°. 
This  rapidity  of  the  pulse-beat  is  almost  pathognomonic  of  scarlatina. 
The  skin  is  hot  and  dry.  Hilton  Fagge  says  that  from  the  time 
of  Addison  the  pungent  heat  of  the  skin  in  scarlet  fever  has  been 
spoken  of  at  Guy's  Hospital  as  comparable  only  with  that  which  is 


162  SCARLATINA. 

to  be  felt  in  acute  pneumonia  (calor  mordax).  The  tonsils,  soft 
palate,  and  uvula  are  deeply  injected  and  often  more  or  less 
swollen  with  pappy  exudation,  resembling  ulcers,  upon  their  surface. 
They  are  plum-coloured.  The  neighbouring  lymphatic  glands  in 
the  neck  also  are  frequently  swollen. 

The  Schneiderian  mucous  membrane  and  the  conjunctiva  are 
seldom  engaged — thus  affording  a  diagnostic  from  measles. 

III.  Stage  of  Eruption. — The  rash  generally  shows  itself  within 
12  or  24  to  30  hours  from  the  first  symptoms.  It  may  be  detected 
very  early  on  the  sides  of  the  neck  and  over  the  chest,  as  well  as 
in  the  neighbourhood  of  large  joints.  It  afterwards  spreads  to 
parts  of  the  face,  to  the  abdomen,  and  over  the  limbs.  Thomas 
insists  that  only  the  forehead  and  temples  are  invaded  by  the  rash, 
the  cheeks  showing  only  the  ordinary  flush  of  fever.  The  centre 
of  the  chin  and  a  zone  round  the  mouth  usually  remain  free 
from  it. 

The  rash  consists  of  minute  red  dots,  with  a  general  or  patchy 
suffusion  of  the  skin,  of  a  bright  scarlet  colour,  which  suggested  to 
Sir  Thomas  Watson,  Bart.,  a  comparison  to  the  colour  of  a  boiled 
lobster.  On  the  forearms  and  legs  and  on  the  backs  of  the  hands 
and  feet,  the  papules  are  larger  and  more  prominent  than  else- 
where. The  palms  and  soles  show  only  a  faint  diffused  blush. 
The  eyelids,  cheeks,  hands,  and  feet  usually  swell  slightly.  Bouchut 
drew  attention  to  a  sign  of  some  diagnostic  value,  which  is  called 
the  Tache  scarlatinale.  This  is  a  white  stripe  or  streak  which 
develops  and  lasts  for  a  few  moments  when  the  finger  is  drawn 
across  the  reddened  surface — the  contractile  power  of  the  cutaneous 
arterioles  being  increased.  Accidental  pressure,  by  the  bedclothes, 
&c,  produces  a  precisely  similar  effect,  which  is  well  represented 
in  Plate  XXII.  of  Willan  and  Bateman's  "  Delineations  of  Cuta- 
neous Diseases."  Probably  nowhere  is  the  eruption  so  marked  as 
on  the  abdomen  and  along  the  inside  of  the  thighs. 

Sometimes  a  "millet-seed"  rash  of  tiny  vesicles  {miliaria)  is 
observed.  These  become  filled  with  a  milky  (lactescent)  fluid  after 
36  to  48  hours.  In  other  cases  the  eruption  is  blotchy,  macular, 
or  papular.     According  to  Trousseau,  the  amount  of  the  rash  is  in 


SCARLATINA.  162 

general  proportionate  to  the  severity  of  the  attack,  but  in  compli- 
cated or  malignant  cases  it  may  be  badly  developed. 

The  rash  reaches  its  limits  by  the  second  or  third  day,  then 
fades  gradually,  leaving  persistent  blood-coloured  (petechial)  lines 
in  the  folds  in  front  of  the  elbows,  in  the  axillae,  and  popliteal 
spaces.      These  streaks  may  be  of  use  for  diagnosis. 

The  appearances  presented  by  the  tongue  in  scarlet  fever  are 
characteristic.  At  first,  it  is  covered  with  a  thick,  creamy,  white 
fur,  through  which  the  enlarged  and  hyperasmic  papilla?  project  as 
little  scarlet  protuberances.  The  fur  is  soon  shed  (early  desquama- 
tion), leaving  the  tongue  red  and  raw,  so  as  to  resemble  a  ripe 
strawberry — hence  the  expression  "  strawberry-tongue"  and  "  cat's 
tongue." 

The  fever  runs  very  high  in  this  stage,  and  the  pulse  beats  very 
quickly  (140-160). 

Defervescence  is  gradual,  extending  over  from  3  to  8  days.  The 
temperature  "  spikes"  slightly  in  the  evenings,  but  remits  in  the 
morning.  To  such  a  temperature  chart  Wunderlich  assigns  the 
name  "  easel-like."  This  term  will  be  explained  further  on,  under 
the  heading  "  Temperature." 

IV.  Stage  of  Desquamation. — The  process  of  "  peeling"  sets  in 
on  the  neck  and  chest  between  the  sixth  and  ninth  days ;  then  it 
affects  the  limbs,  the  hands,  and  lastly  the  soles  of  the  feet. 
Branny  scales  come  off  from  the  face  (furfuraceous  desquamation), 
flakes  of  cuticle  are  shed  from  the  trunk,  and  sometimes  "  gloves  " 
of  skin  from  the  hands  and  feet — even  the  nails  may  be  shed. 
Much  more  frequently,  however,  interference  with  the  nutrition  of 
the  nails  is  shown  by  the  formation  of  a  transverse  groove  upon 
them.  This  was  fully  described  by  A.  Vogel  in  the  case  of  typhus 
fever,  and  is  illustrated  by  drawings  in  Murchison's  work  on  the 
"  Continued  Fevers  of  Great  Britain."  Dr.  Samuel  Wilks  drew 
special  attention  to  this  atrophic  furrow  in  the  nails  of  scarlet 
fever  patients. 

In  this  stage,  albuminuria  often  makes  its  appearance,  one  reason 
being  the  shedding  of  the  tubal  epithelium  in  the  kidneys,  in  con- 
sequence of  which  albumen  escapes  into  the  urine. 


164  SCARLATINA. 

Hilton  Fagge  describes  the  process  of  desquamation  as  taking 
place  in  a  manner  which  I  have  often  observed.  "  The  first  step," 
he  says,  "  towards  the  throwing  off  of  the  epidermis  at  a  particular 
spot  is  often  the  formation  of  a  little  opaque  raised  vesicle,  very- 
like  thdse  which  are  characteristic  of  eczema,  but  dry;  this  breaks 
at  the  summit,  leaving  a  free  edge  in  the  shape  of  a  ling,  which 
gradually  becomes  larger  and  larger.1' 

The  duration  of  the  stage  of  desquamation  is  really  indefinite — 
in  some  cases  lasting  for  a  fortnight  only,  in  others  for  several 
weeks — perhaps,  even  months. 

Relapse  is  a  very  infrequent  phenomenon  in  scarlatina.  The 
most  recent  contribution  to  the  literature  of  the  subject  will  be 
found  in  the  number  of  the  Edinburgh  Medical  Journal  for  October, 
1891,  in  which  Mr.  George  P.  Boddie  reports  two  cases  of  what  he 
terms  "  a  true  relapse  or  recrudescence  in  scarlet  fever,"  illustrated 
by  the  temperature  charts.  Of  the  nature  of  the  second  case  Mr. 
Boddie  speaks  with  some  reserve,  but  he  has  no  doubt  as  to  the 
first  case.  A  boy,  aged  fourteen,  passed  through  an  ordinary  attack 
of  scarlatina  simplex,  followed  by  slight  albuminuria  and  desqua- 
mation, partly  scurf-like,  partly  flaky.  He  was  out  and  about 
when,  on  the  37th  day,  he  was  again  seized  with  symptoms  of 
scarlatina.  Desquamation  began  on  the  7th  day,  and  was  more 
extensive  than  in  the  first  attack.  At  the  end  of  five  weeks — 72 
days  from  the  first  illness — the  boy  was  perfectly  well. 

Mr.  Boddie  has  appended  to  his  clinical  record  a  very  full 
'resume  of  the  literature  on  the  subject  of  "Relapse  in  Scarlatina." 
Trojanowskya  states  that  among  300  cases  (260  children  and  40 
adults)  he  has  seen  18  relapses  (15  children  and  3  adults),  that  is, 
6  per  cent.  Thomas  and  Kbrner,  both  of  Leipzig,  distinguished 
between  what  they  call  a  pseudo-relapse  (em  Pseudo-recidiv)  and 
a  true  relapse  (ein  wahres  Recidiv.)  These  authors  have  severally 
seen  cases  of  the  latter.  Kbrner,  in  particular,  supplements  his 
paper  by  giving  notes  of  38  cases  of  true  relapse  as  reported  by 
various  writers,  whom  he  names.     Henoch13  gives  notes  of  8  cases. 

a  Jahvbuch  fur  Kinderheilkunde.     1873. 

b  Lectures  on  Children's  Diseases.    New  Syd.  Soc.     Vol.  If.,  p.  232,  et  seq. 


SCARLATINA.  In*  5 

Gumprecht,  among  228  cases  of  scarlatina  at  the  Friedrichshain 
Hospital,  says  he  met  with  13  "  pure  cases  of  relapse" — i.e.,  b'l  per 
cent. 

French  writers,  such  as  Jaccoud,a  and  Rilliet  and  Barthezb 
express  the  opinion  that  scarlatina  is  capable  of  recrudescence  or 
relapse  like  typhoid  fever,  and  that  we  possess  well  authenticated 
cases  of  this  phenomenon. 

English  writers  are  more  sceptical.  Thus  Hilton  Faggec  asserts 
that  "  relapses  are  seldom  or  never  seen."  Drs.  Ashby  and  Wright, 
in  their  Handbook  on  the  Diseases  of  Children  (page  213)  say, 
"  Reinfection  or  relapses  are  said  to  take  place  in  some  instances.'' 
In  supposed  cases  of  relapse  which  came  under  their  own  notice, 
"  there  was  considerable  doubt  as  to  the  correctness  of  the  original 
diagnosis." 

Dr.  E.  0.  Hopwood,d  of  the  London  Fever  Hospital,  estimates, 
however,  that  "  a  relapse,  or  true  second  attack  of  scarlet  fever, 
occurs  in  about  one-half  per  cent,  of  cases  at  any  time  from  the 
tenth  day  of  the  first  attack,  and  is  followed  by  a  second  descpia- 
mation.     It  may  be  of  any  grade  of  severity." 

Fiirbringer,  the  writer  of  the  brilliant  article  on  "  Scharlach  "  in 
the  Real-Encyclopddie  der  gesammten  Heilkunde,  states  that  it  always 
appeared  to  him  that  the  relapse  was  "  a  fever  following  the  true 
initial  scarlatina,  independent  of  it,  caused  by  no  apparent  compli- 
cation, of  very  variable  type,  and  lasting  for  days  or  wTeeks." 

As  for  my  own  experience,  I  cannot  recall  a  single  instance  in 
which  a  true  relapse  came  under  my  cognisance,  although  I  have 
often  observed  accidental  febrile  movements  during  convalescence 
from  scarlatina. 

a  Traiti  de  Pathologie  Interne.     1883.     III.     558. 

b  Traite  des  Maladies  des  Infants.     1891.     III.     153. 

c  Principles  and  Pract.  of  Med.     Vol.  I.,  p.  216.     1886. 

A  Did.  Pract.  Med.    Edited  by  J.  K.  Fowler.     1890.    Art.  "Scarlet  Fever." 


166 


CHAPTER  XVII. 

Scarlatina  (continued). 

Aberrant  Forms — Complications  and  SEQUEiiE — 
Temperature. 

Irregular  or  aberrant  forms  of  scarlatina  :  (1.)  Rudimentary  or  abor- 
tive :  (a.)  simple  scarlatinal  angina  (scarlatina  faucium),  (/3.)  latent  scarlatina 
(scarlatiue  fraste)  ;  (2.)  Scarlatina  anginosa — diffuse  cellulitis  of  neck  ("tippet- 
neck"),  diphtheria  ;  (3.)  Scarlatina  maligna  :  (a.)  Angina  maligna,  (/3.)  ataxic 
scarlatina,  (y.)  hemorrhagic  scarlatina — "Scbarlacbtypbus." — Complications 
and  SequeLjE  :  Diphtheria,  acute  rheumatic  arthritis  and  serous  inflammations, 
acute  desquamative  nephritis,  pleuritis,  bubonic  swellings,  pyaemia,  boils  and 
abscesses,  otitis,  eye  affections,  eczema,  chorea. — Temperature  ranges  in 
Scarlatina. 

In  the  last  Chapter  a  word-picture  was  attempted  to  be  drawn  of 
scarlet  fever  as  the  disease  presents  itself  in  a  typical  or  normal 
case.  But  a  striking  feature  in  the  malady  is  its  polytypical  cha- 
racter, the  great  variability  of  its  symptoms  and  of  its  course.  It 
will  be  necessary,  therefore,  shortly  to  describe  some  of  its  leading 
irregular  or  aberrant  forms,  as  Hilton  Fagge  calls  them. 

1.  Of  the  rudimentary  or  abortive,  and  therefore  mild  and 
favourable  forms,  the  most  frequent  is  (1.)  Simple  Scarlatinal 
Angina.  This  is  observed  usually  in  adults,  whose  predisposition 
to  the  disease  is  slight,  during  the  prevalence  of  an  epidemic.  Its 
features  are — fever  of  moderate  intensity,  slight  sore  throat  with 
redness  and  some  swelling  of  the  mucous  membrane,  pain  in  the 
neck,  and,  it  may  be,  enlargement  of  the  cervical  glands.  This 
mild  scarlatinal  angina  was  described  by  Dr.  Alex.  Tweedie,  in  an 
excellent  monograph  on  Scarlatina,*  under  the  name  Scarlatina 
Faucium.  In  Graves's  "  Clinical  Lectures  "  b  will  be  found  a  series 
of  cases  of  it  detailed  by  the  late  Dr.  John  Ridley,  of  Tullamore, 

a  The  Cyclopcedia  of  Practical  Medicine.    London  :   1834.    Vol.  III.     Art. 
"Scarlatina." 

b  hoc.  cit.     Page  247. 


SCARLATINA.  167 

King's  County.  Thomas*  says :  "  Such  attacks  generally  disappear 
in  a  few  days,  but  they  should  receive  the  same  attention  which  is 
paid  to  the  unmistakable  disease ;  every  throat  affection  during  a 
scarlet  fever  epidemic  is  suspicious !  "  This  is  all  the  more  neces- 
sary as  the  most  malignant  forms  of  the  disease  may  arise  from 
scarlatina  faucium.  (2.)  In  other  cases,  the  throat  affection  is 
absent  or  so  trifling  that  it  does  not  account  for  the  existing  fever. 
There  may  be  a  slight  rash,  and  the  cervical  glands  may  be  enlarged. 
In  such  attacks,  joint  affections  of  a  rheumatic  nature  or  kidney 
trouble  may  supervene.  This  is  disguised  or  Latent  Scarlet 
Fever — the  form  to  which  Trousseau  gave  the  name  of  "  defaced 
scarlatina "  (Scarlatine  fruste).  As  an  inscription  is  defaced  by 
being  in  part  obliterated,  so  a  disease  may  be  defaced  by  the 
absence  of  some  of  its  prominent  and  distinguishing  features. 

2.  In  marked  contrast  to  the  foregoing  mild  forms,  we  often 
meet  with  that  severe  variety  to  which  the  name  Scarlatina  anginosa 
is  given.  It  is  the  second  of  the  three  classical  forms.  In  this 
anginose  variety  the  constitutional  disturbance  and  fever  are  well 
marked,  and,  in  addition,  the  patient  as  early  as  the  second  day  com- 
plains of  stiffness  and  pain  about  the  neck  and  jaws,  and  under  the 
ears,  the  throat  feels  rough,  deglutition  is  difficult  and  painful,  and 
there  is  some  hoarseness.  The  tonsils  are  swollen,  and  of  a  deep 
purple  or  plum-like  colour.  On  their  surface  small  whitish  specks 
of  pappy  or  pultaceous  exudation  appear.  These  resemble  ulcera- 
tions, but  are  really  accumulations  of  secretion  from  the  mucous 
crypts  or  follicles — which  have  taken  on  increased  action — and  of 
epithelium,  which  is  already  desquamating  freely.  The  mucous 
membranes  of  the  pharynx,  mouth,  and  nose,  all  share  in  this 
affection,  so  that  both  respiration  and  deglutition  may  be  seriously 
interfered  with ;  an  offensive  sanious  discharge  takes  place  from 
the  nostrils,  the  breath  is  foetid,  the  voice  becomes  nasal,  and  drinks 
return  by  the  nose.  The  scarlatinal  affection  of  the  nasal  mucous 
membrane  may  also  extend  to  the  cavities  adjacent  to  the  nose 
especially  the  antrum  of  Highmore ;  or  not  infrequently  to  the 
Eustachian  tubes,  in  which  latter  case  deafness  of  a  temporary, 
a  Von  Ziemssen's  Cyclopaedia  of  Medicine.     Art.  "  Scarlatina." 


16$  SCARLATINA. 

sometimes  of  a  permanent,  nature,  is  added  to  tbe  patient's 
troubles. 

Nor  does  the  mischief  end  here.  In  this  form  of  the  disease,  the 
tonsils  may  suppurate,  or,  still  worse,  become  gangrenous  after  an 
abscess  has  formed  and  burst — the  destructive  process  extending  to 
and  eating  away  the  arches  of  the  palate,  the  uvula,  and  even  the 
whole  of  the  soft  palate  itself.  Ulceration  of  the  tonsils  may  also 
lead  to  erosion  of  the  internal  carotid  artery,  necessitating  ligature 
of  the  common  carotid  of  the  same  side. 

It  is  in  scarlatina  anginosa,  also,  that  after  the  eighth  day  the 
cervical  glands  swell  sometimes  enormously,  a  low  erysipelatous  or 
phlegmonoid  inflammation  engaging  the  cellular  tissue  of  the  neck. 
The  swelling  which  attends  this  "  diffuse  cellulitis  "  gives  rise  to 
the  expression  "tippet-neck" — a  condition  said  to  be  fatal  if  it 
involves  both  sides  of  the  neck.  The  brawny  swelling  is  often 
white,  smooth,  glossy,  and  hard  as  a  board;  it  pits  on  pressure, but 
conveys  no  sense  of  fluctuation.  It  is  situated  at  the  angle  of  the 
jaw,  or  involves  the  whole  lower  jaw,  stretching  upwards  to  the 
temples  and  downwards  to  the  clavicles.* 

The  diseased  mucous  membranes  in  scarlatina  anginosa  lastly 
afford  a  fertile  soil  for  the  growth  of  the  micro-organisms  of 
diphtheria — the  Streptococcus  described  by  Oertel,  and  the  Bacillus 
of  Loffler.  As  a  matter  of  fact,  diphtheria  is  a  not  uncommon 
complication  of  the  disease. 

3.  Some  of  the  severer  forms  of  scarlatina  anginosa  just  described 
might  justly  be  included  under  the  heading  Scarlatina  maligna. 
But  apart  from  the  malignant  form  of  scarlatina  anginosa,  formerly 
called  Angina  Maligna  (Fothergill,  1754),  the  term  Scarlatina 
maligna  is  reserved  specially  for  two  terrible  varieties  of  the 
malady — Ataxic  Scarlatina  and  Hsemorrhagic  Scarlatina. 

Nervous  or  Ataxic  Scarlet  Fever  is  ushered  in  with  rigors, 
convulsions,  and  even  tonic  spasms  with  trismus,  incessant  vomiting 

a  A  good  account  of  "  Diffuse  Cellulitis  of  the  Neck,"  by  Mr.  Henry  Gray 
Croly,  President  of  the  Royal  College  of  Surgeons  in  Ireland,  will  be  found  in 
the  Dublin  Journ.  of  Med.  Science  for  May,  1873,  Vol.  LV.,  page  407,  Not.  17, 
Third  Series. 


SCARLATINA.  169 

find  diarrhoea,  wakefulness,  agitation,  and  restlessness  with  deli- 
rium, and  high  fever  (hyperpyrexia).  A  temperature  of  115°  F. 
was  observed  by  the  late  Dr.  Bathurst  Woodman  in  some  patients,8 
but  this  must  be  considered  as  altogether  phenomenal.  The 
maximum  observed  by  Wunderlich  was  110''6°  F.  (43*o°  C)  The 
foregoing  symptoms  are  quickly  followed  by  another  group 
indicative  of  profound  nervous  prostration  (ataxia) — namely, 
muscular  tremors  (subsultus  tendinum),  plucking  at  the  bed-clothes 
{carphology  or  Jloccitatio),  thecoma  vigil  described  by  Sir  Win.  Jenner, 
Bart.,  dilated  pupils,  coma,  quick  shallow  breathing,  and  extreme 
rapidity  and  feebleness  of  the  heart's  action,  and  profuse  cold  or 
clammy  sweating.  Needless  to  say  that  such  attacks  prove  rapidly 
fatal.  The  rash  is  badly,  if  at  all,  developed,  and  the  diagnosis  of 
scarlet  fever  depends  largely  on  the  occurrence  of  undoubted  cases 
in  the  same  house  or  the  immediate  neighbourhood. 

In  the  other  variety  of  malignant  scarlet  fever,  with  early  severe 
constitutional  symptoms  of  a  "typhoid,"  "ataxic,"  or  "septic" 
character,  the  rash  comes  out  late  and  imperfectly.  Its  colour  is 
dark — "  a  livid  violet,"  as  Hilton  Fagge  calls  it — and  reddish  brown 
points  of  hEemorrhage,  with  petechias  and  vibices,  are  found 
scattered  over  a  large  part  of  the  surface  in  children — less  exten- 
sively in  adults,  over  the  neck,  chest,  back,  and  skin  near  the  large 
joints.  When  the  rash  presents  this  hemorrhagic  form  the  tonsils 
and  gums  are  generally  of  an  abnormally  dark  colour  (Mayr).  Such 
a  rash  is  figured  in  Plate  XXII.  of  Willan  and  Bateman's  "  Deli- 
neations of  Cutaneous  Diseases."  Haemorrhages  take  place  from 
the  mucous  membranes,  especially  of  the  nose,  colon,  and  urinary 
passages. 

In  women,  menorrhagia  may  occur.  The  internal  organs  may 
be  the  seat  of  haemorrhages  in  both  sexes,  and  finally  pleuritic  or 
pericardial  hemorrhagic  extravasations  may  take  place  (Thomas). 

To  these  grave  forms  of  the  disease  Hebra  gave  the  name  of 
Scharlachtyphus,  or  Scarlatinal  Dissolution  or  Decomposition  of 

a  Medical  Mirror,  February,  1865.  See  note  2,  page  204  of  Dr.  Woodman's 
Translation  of  "Wunderlich 's  Medical  Thermometry  lor  the  New  Sydenham 
Society.      London.     1871. 


170  SCARLATINA. 

the  Blood,  regarding  them  as  instances  of  a  scarlatina  without 
localisation  and  affecting  the  blood  alone  (eine  Scarlatina  ohm 
Localisation,  ein  im,  Blute  verlaufender  Scharlach).8, 

Complications  and  Sequelae. — Among  the  complications  of  the 
acute  stages  of  scarlet  fever  we  may  include  the  ataxic  symptoms 
above  described,  the  acute  haemorrhagic  diathesis  (haemophilia)  of 
the  malignant  variety,  and  the  sore-throat  of  the  anginose  form, 
with  its  consequences.  But,  in  addition  to  these,  mention  must  be 
made  of  the  following  complications  : — 

1.  Diphtheria,  in  which  the  mucous  membranes  of  the  mouth, 
pharynx,  and  nostrils  become  covered  to  a  greater  or  less  extent 
with  a  false  membrane  of  an  ashy  gray  colour  and  leathery  con- 
sistence, closely  adherent,  and,  if  removed,  quickly  replaced  on  the 
ulcerated  and  bleeding,  or  simply  ulcerated  surface.  This  com- 
plication is  almost  invariably  associated  with  albuminuria  and  is 
generally  followed  by  various  paralytic  symptoms  and  dangerous 
heart  failure,  or  attacks  of  angina  pectoris  vaso-motoria  of  Nothnagel. 

2.  Acute  rheumatic  arthritis  and  inflammations  of  the  serous 
membranes  occur  tolerably  often  in  the  course  of  scarlet  fever— all 
the  phenomena  of  an  attack  of  acute  rheumatism  may  be  present, 
and  permanent  endocardial  mischief  may  result. 

3.  Acute  desquamative  nephritis  generally  sets  in  towards  the 
close  of  the  first,  or  in  the  second  week,  or  at  any  time  during  con- 
valescence. It  is  a  parenchymatous  and  interstitial  (E.  Klein) 
inflammation,  and  is  ushered  in  with  suppression  of  urine  (anuria)  or 
haematuria,  oedema  of  the  eyelids,  pallor,  thirst,  and  high  temperature. 
When  the  urine  is  passed  it  is  found  to  be  scanty,  highly  albuminous, 
as  the  result — (1)  of  haemorrhage  from  intense  hyperemia,  (2)  of 
an  abnormal  perviousness  of  the  walls  of  the  glomeruli  in  conse- 
quence of  which  transudation  of  albumen  takes  place  into  the  urine 
(Strumpell).  The  urine  also  is  of  high  specific  density  (1020-1030), 
smoky  appearance,  and  acid  reaction.  Some  of  the  densest  urines  are 
met  with  in  acute  scarlatinal  nephritis,  and  Dr.  Walter  G.  Smith  b 

aHebra.     Diseases  of  the  Skin.     New  Syd.  Soc.     1866.     Vol.  I.,  page  201. 
6  Saundby.      Lectures  on  Briyht's  Disease.      Bristol :    John  Wright  &  Co 
1889.    Page  177. 


SCARLATINA. 


171 


has  recorded  a  sp.  grav.  of  1065  in  one  instance.  Under  the  micro- 
scope altered  red  blood  corpuscles  and  granular,  bloody,  and  epi- 
thelial tube-casts  are  visible.  Barthez  and  Rilliet  have  observed 
anasarca  in  one-fifth  of  all  their  cases  of  scarlet  fever.  The  affec- 
tion may  terminate— (1)  in  recovery;  (2)  in  death,  with  convul- 
sions ;  or  (3)  very  rarely  in  chronic  general  nephritis. 

4.  Pleuritis,  with  purulent  effusion  as  in  any  septic  fever. 

5.  Bubonic  swellings,  which  occur  chiefly  in  the  neck  towards 
the  decline  of  the  rash. 

During  convalescence,  the  sequelae  most  likely  to  occur  are — 

1.  Pyaemia. 

2.  Boils  and  abscesses. 

3.  Otitis,  with  perforation  of  the  membrana  tympani  from  pres- 
sure by  pus  pent  up  in  the  middle  ear.  Wendt  contrasts  the 
catarrhal  inflammation  of  the  Eustachian  tube  or  of  the  middle  ear 
which  accompanies  measles,  with  the  suppurative  otitis  media  of 
scarlatina.  A  still  more  serious  condition  is  when  mastoid  disease 
occurs,  with  its  consequences — inflammation  of  the  dura  mater, 
thrombosis  of  the  cerebral  sinuses,  pulmonary  embolism  and  puru- 
lent infiltration,  cerebral  abscess,  panophthalmitis  from  embolism. 

5.  Eye  affections,  namely,  diphtheritic  conjunctivitis,  atrophic 
keratitis,  panophthalmitis,  retinitis  albuminurica. 

6.  Eczema. 

7.  Chorea,  or  St.  Vitus's  Dance  {Dance  de  St.  Guy),  in  two,  three, 
or  even  six  months  after  the  attack. 

Temperature.— The  behaviour  of  the  temperature  in  scarlet 
fever  is  less  typical  than  it  is  in  smallpox  or  measles.  Usually, 
however,  one  of  the  first  symptoms  is  a  rapid  and  continuous  rise 
of  temperature  in  a  few  hours  to  103°  or  104°  F.  With  the 
coming  out  of  the  rash  the  thermometer  may  be  seen  to  rise  slowly, 
with  only  slight  morning  remissions,  the  height  finally  reached 
being  almost  always  above  104°,  very  commonly  over  104*9°,  but 
seldom  in  cases  which  terminate  favourably  over  105*8°  (Wunder- 
lich). 

As  a  rule,  the  intensity  of  the  fever  bears  a  tolerably  close 
relation  to  that  of  the  exanthem. 


172  SCARLATINA. 

When  the  rash  begins  to  fade,  defervescence  commences.  It  may; 
occur  quickly  and  uninterruptedly  by  crisis;  but  in  an  overwhelming 
majority  of  cases  it  is  protracted,  requiring  from  three  to  eight  days 
for  its  completion.  "As  a  rule,"  says  Wunderlich,  "  it  occurs  in  tin's 
fashion,  that  from  day  to  day  the  temperature  gets  gradually  lower 
and  lower,  and  slopes  like  an  easel,  or  almost  easel- wise  (Staffel- 
weise),  or  goes  down  with  trifling  remissions,  falling  especially  at 
night,  remaiuing  about  the  same  from  morning  to  evening,  or 
perhaps  sinking  a  little  till  it  reaches  the  normal."  It  is  only  very 
seldom  that  a  remitting  defervescence  produces  a  remote  resem- 
blance to  that  which  is  peculiar  to  typhoid  or  enteric  fever. 

Complications,  of  course,  interfere  with  the  usual  temperature 
ranges. 

A  subnormal  tempei'ature — seldom,  however,  below  96'8°— • 
accompanied  by  other  symptoms  of  collapse,  is  not  of  infrequent 
occurrence  towards  the  close  of  the  stage  of  defervescence. 

An  anomalous  course  of  temperature  is  not  uncommon — thus,  it 
may  be  persistently  rather  low— a  condition  which  does  not  exclude 
danger,  and  by  no  means  guarantees  a  favourable  terminatiou. 

Again,  in  Scharlachtyphus  (the  so-called  "  typhoid-scarlatina  "), 
the  temperature  may  remain  more  or  less  high  for  a  fortnight  or 
longer  after  the  rash  has  faded.  It  is  sub-continuous  or  remittent 
in  form,  yet  in  general  it  takes  a  descending  course. 

In  fatal  cases,  the  temperature  is  very  erratic,  but  sometimes  it 
reaches  very  high  degrees  indeed.  Wunderlich  met  with  a  pre- 
agonistic  reading  of  43'5°  C.  (110-3°  F.),  and  Woodman's  still 
more  extraordinary  observations  have  been  already  noted. 

Plate  III.  contains  a  series  of  charts  culled  from  my  own  Notes, 
which  will  fairly  illustrate  the  behaviour  of  the  temperature  iu 
scarlatina. 


173 


CHAPTER  XVIII. 

Scarlatina  {continued). 
Pathology,  Diagnosis,  and  Prognosis. 

Pathology  op  Scarlatina  :  The  blond — the  cutaneous  affection— the  throat 
and  sub-maxillary  glai'ds. — Cerebro-spinal  system. — The  abdomen— small 
intestine  — psorenterie  —  kidneys . — G-lomerulo-tubal  Nephritis  (Klebs). — E. 
Klein's  views. — Diphtheritic  Pyelitis. — Changes  in  the  urine. —Dropsy.— 
Inflammations  of  (a.)  serous  membranes,  (/3.)  of  synovial  membranes  of  the 
joints. — The  heart — acute  parenchymatous  myocarditis— cardiac  failure.— 
Diagnosis:  Erythema,  Smallpox,  Measles,  Rbtheln,  Erysipelas,  Diphtheria, 
Acute  Rheumatism. —Prognosis  and  Mortality. —Causes  of  Death. 

Pathology.  — The  blood  is  darkened  in  colour,  thin,  and  generally 
contains  an  excess  of  white  blood  corpuscles.  The  walls  of  the 
blood-vessels  often  imbibe  the  colouring  matter  of  the  blood, 
and  thus  appear  inflamed  (Thomas).  The  cutaneous  affection  of 
scarlatina  is  not  merely  a  hyperemia,  but  is  also  characterised 
by  an  exudation  into  the  rete  Malpighii.  Histologically,  Loschner, 
of  Vienna,  found  exudation  cells  in  this  structure,  and  Dr.  Hilton 
Fagge  thinks  they  were  probably  seen  by  Dr.  Fenwick  also,  who 
further  observed  that  the  basement  membrane  of  the  sweat-glands 
was  thickened,  and  their  channels  were  obstructed  by  an  overgrowth 
of  epithelium  or  by  extravasated  blood.  That  the  eruption  bears 
no  definite  relation  to  these  glands  or  to  the  hair  follicles,  seems  to 
follow  from  a  case  reported  by  Landenberger  and  quoted  by 
Thomas,a  in  which  it  did  not  fail  to  develop  itself  over  an  immense 
cicatrix  from  a  burn  which  extended  over  the  thigh,  abdomen,  and 
back,  "  the  skin  having  been  destroyed  in  its  whole  thickness." 
Slight  desquamation  followed,  and  the  scar  underwent  diphtheritic 
necrosis  throughout  a  portion  as  large  as  the  hand. 

The  process  of  desquamation  may  involve  the  nails  of  the  fingers 
and  toes,  and  the  hair  may  fall  out.  Lentin  and  Bicker  have  seen 
warts  drop  off  after  scarlet  fever. 

aArt.  "Scarlatina,"  in  von  Ziemssen's  Cyclopcedia  of  Practical  Medicine. 
Page  212. 


174  SCARLATINA. 

The  changes  in  the  organs  of  the  throat  are  as  essential  features 
in  the  pathology  of  this  disease  as  the  exanthem  itself.  They  have 
been  sufficiently  described  under  the  heading  Scarlatina  anginosa. 

Barthez  and  Rilliet  found  the  submaxillary  glands  enlarged, 
hypersemic  and  softened,  and  in  a  later  stage,  grayish,  soft,  and  the 
seat  of  purulent  infiltration.  The  affection  of  the  cellular  tissue  is 
undoubtedly  inflammatory,  and  probably  results  from  septic  poison- 
ing, or  from  haemorrhage — it  is  a  diffuse  cellulitis. 

Notwithstanding  the  occurrence  of  severe  cerebral  and  spinal 
symptoms  in  bad  cases,  the  cerebro-spinal  pathology  of  scarlet 
fever  may  be  regarded  as  a  negative  quantity. 

As  regards  the  abdomen  and  its  contents,  the  only  specific 
changes  are  those  met  with  in  the  small  intestine  and  in  the 
kidneys.  From  the  duodenum  to  the  caecum  and  colon  the  mucous 
membrane  is  more  or  less  injected,  and  Brunner's  and  Lieberkiihn's 
glands,  as  well  as  the  solitary  follicles  and  Peyer's  patches,  are 
swelled  and  prominent,  giving  rise  to  the  appearance  known  as 
psorenterie. a  Deiters  describes  the  patches  as  being  sometimes 
ulcerated,  when  a  most  striking  resemblance  to  the  changes  found 
in  typhoid  or  enteric  fever  is  presented. 

Next  to  the  skin  and  throat,  the  kidneys  are  the  organs  most 
frequently  affected  by  scarlatina.  Early  in  the  disease  a  catarrhal 
condition  is  found,  the  epithelium  in  the  medullary  substance 
being  cloudy,  desquamating  in  large  masses,  and  being  rapidly 
washed  away.  Later,  a  true  parenchymatous  nephritis  sets  in, 
when  the  cortical  substance  is  particularly  affected.  In  the  severer 
cases,  the  capsules  of  the  kidneys  are  easily  detached  and  the 
organs  are  enormously  enlarged  (Biermer). 

Klebs  has  occasionally  found  the  kidneys  firm  and  hyperaemic 
but  not  enlarged,  with  nucleolar  growths  in  the  connective  tissue 
between  the  capillary  loops  of  the  Malpighian  corpuscles,  com- 
pletely compressing  the  calibre  of  the  vessels  and  so  causing  anuria. 
The  morbid  process  begins  in  the  Malpighian  corpuscles,  and  then 

a  Gk.  ty&pa,  scabies  or  itch,  mange  ;  evrepov,  the  intestine.  The  French  use 
the  word  Psore  as  a  geDeric  title  for  vesicular  and  pustular  maladies  of  the 
skin,  and  the  idea  of  roughness  is  also  connected  with  the  Greek  tydpa. 


SCARLATINA.  175 

follows   the   course   of    the   convoluted   tubes    (Glomerulo-tubal 
Nephritis). 

Even  when  no  renal  symptoms  are  present,  E.  Wagner  says  that 
the  kidneys  are  in  a  condition  of  congestive  hyperemia  either 
with  or  without  a  more  or  less  marked  degree  of  albuminous  infil- 
tration. Very  rarely  the  severer  forms  of  parenchymatous  nephritis 
are  met  with  even  in  the  beginning  of  scarlet  fever;  as  a  rule, 
however,  not  before  the  end  of  the  second,  or  in  the  third  week. 

So  far  as  I  know,  the  fullest  account  of  the  pathological  changes 
in  the  kidney  induced  by  scarlatina  is  contained  in  a  communica- 
tion made  to  the  Pathological  Society  of  London  by  Dr.  E.  Klein, 
on  April  17,  1877.a 

The  early  changes  are  met  with  in  the  vascular  apparatus  and 
certain  of  the  glandular  parts  of  the  kidney.  The  vascular  changes 
are  limited,  for  the  most  part,  to  the  cortical  portion  of  the  organ. 
They  are — (1.)  Increase  of  nuclei  (probably,  epithelial  nuclei), 
covering  the  glomeruli  of  the  Malpighian  corpuscles.  (2.)  Hyaline 
degeneration  of  the  afferent  arterioles  of  the  Malpighian  corpuscles. 
(3.)  Multiplication  or  germination  of  the  nuclei  of  the  muscular 
coat  of  the  minute  arteries,  and  a  corresponding  increase  in  thick- 
ness of  the  wall  of  these  vessels. 

The  changes  referring  to  the  glandular  part  of  the  kidney  are 
indications  of  parenchymatous  nephritis  consisting  in  swelling 
up  of  the  epithelial  lining  of  some  of  the  convoluted  tubes  and 
germination  of  the  nuclei  of  epithelial  cells,  especially  in  portions 
of  the  ascending  tubules  lying  close  to  an  afferent  arteriole  of  a 
Malpighian  corpuscle.  Granular  matter,  and  even  blood,  may  be 
found  in  the  cavity  of  Bowman's  capsules  and  in  the  convoluted 
tubes,  and  also  cloudy  swelling  and  granular  disintegration  of  the 
epithelium  in  some  parts  of  the  convoluted  tubes.  In  some  cases 
there  appears  to  be  detachment  of  epithelium  from  the  membrane 
of  the  larger  ducts  of  the  pyramids. 

Klein  considers  that  the  multiplication  of  the  muscle-nuclei  and 

a  The  Anatomical  Changes  of  the  Kidney,  Liver,  Spleen,  and  Lymphatic  Gl'inds 
in  Scarlatina  of  Man.  Trans,  of  the  Path.  Soc.  of  London.  1877.  Vol. 
XXVIII.,  p.  430. 


]  76  SCARLATINA. 

the  corresponding  increase  in  thickness  of  the  coat,  accompanied 
by  an  increase  of  thickness  and  number  of  the  muscle-fibres,  does 
not  mean  a  real  hypertrophy.  He  suggests,  also,  that  the  anuria 
and  uraemia  of  scarlatina  are  brought  about,  not,  as  is  supposed  by 
Klebs,  by  a  compression  of  the  vessels  of  the  glomeruli  by  the 
nuclear  germination,  but  by  the  glomeruli  being  shut  out  of  the 
circulation  owing  to  the  changed  state  of  the  arterioles,  which  are 
abnormally  contracted,  probably  under  the  influence  of  some 
stimulus  (perhaps,  some  blood  irritant). 

In  early  cases  the  parenchymatous  changes  found  are  slight. 

The  second  set  of  changes  refer  to  cases  which  died  later  than 
the  first  week,  beginning  with  about  the  ninth  or  tenth  day.  Here 
we  find  changes  due  to  interstitial  as  well  as  parenchymatous 
nephritis — they  are  (1.)  The  appearance  of  round  cells,  lymphoid 
cells,  or  whatever  they  may  be  called,  in  the  connective  tissue  of 
the  kidney;  (2.)  Certain  concomitant  alterations  of  the  urinary 
tubes.  The  infiltration  with  round  cells  is  observable  after  the  end 
of  the  first  week  in  the  connective  tissue  around  the  large  vascular 
trunks,  whence  it  spreads  into  the  basis  of  the  pyramids,  and  espe- 
cially into  the  cortex.  Portions  of  the  latter,  and — very  seldom — 
portions  of  the  basis  of  the  pyramids  also,  are  converted  into  a  pale, 
firm,  round-cell  tissue,  in  which  the  original  urinary  tubes  of  the 
cortex  become  gradually  quashed  and  lost. 

This  interstitial  nephritis  begins  about  the  end  of  the  first 
week,  and  is  followed  by  a  marked  increase  in  the  parenchymatous 
nephritis.  This  latter  consists  in  crowding  of  the  urinary  lubes  with 
lymphoid  cells,  granular  and  fatty  degeneration  of  the  epithelium 
of  the  uriniferous  tubes,  and  the  formation  of  cylinders  of  different 
kinds  in  the  tubes.  The  intensity  of  the  parenchymatous  change 
is,  in  fact,  dependent  upon  the  degree  of  the  interstitial  nephritis. 

A  very  curious  fact,  pointed  out  by  Klein,  is  the  deposit  of  lime 
matter  in  the  epithelium  and  lumen  of  the  urinary  tubes,  first  of 
the  cortex,  then  also  of  the  pyramids  at  an  early  stage  of  scarlatina, 
when  the  kidney  otherwise  shows  only  very  slight  change. 

Biermer,  Coats,  and  Wagner  regard  the  occurrence  of  interstitial 
nephritis  in  scarlatina  as  unusual.  Each  of  these  observers  describes 


SCARLATINA.  177 

one  case  as  unique.  According  to  Klein,  on  the  contrary^  the 
general  rule  is  that  cases  of  scarlatina  which  die  after  about  nine 
or  ten  days  show  more  or  less  well-marked  interstitial  nephritis. 

In  scarlatina  hemorrhagica,  Huguenin  demonstrated  a  diphtheria 
of  the  mucous  membrane  of  the  pelvis  of  the  ureter  (diphtheritic 
pyelitis)  which  had  given  rise  to  copious  hematuria. 

The  changes  in  the  urine  which  mark  the  rise,  progress,  and 
subsidence  of  acute  parenchymatous  nephritis  are  the  following :  — 

1.  An  increasing  turbidity,  with  grayish-white  or  dark-coloured 
sediments,  consisting  of  an  excess  of  epithelium — cloudy  and 
degenerated  or  swollen — granular  detritus,  and  red  and  white  blood 
corpuscles. 

2.  When  haemorrhage  from  the  renal  parenchyma  supervenes, 
the  urine  becomes  reddish-brown,  or  "  smoky,"  and  very  turbid 
from  urates,  depositing  them  and  an  abundance  of  epithelium  and 
casts — bloody,  epithelial,  and  granular.  The  secretion  is  very 
concentrated — shown  by  a  high  specific  gravity  (1025-1030), 
much  diminished  in  quantity,  sometimes  almost  suppressed. 
Albumen  is  present  in  daily  increasing  quantities.  The  albu- 
minuria has  been  already  explained  above  (see  page  170). 

3.  Improvement  is  indicated  by  an  increase  in  the  amount  of 
urine  secreted.  It  becomes  clearer  and  of  lower  specific  gravity, 
loses  its  dark  colour,  no  longer  contains  blood  or  throws  down 
sediments,  and  contains  albumen  in  daily  diminishing  quantity. 
The  tube  casts  are  now  less  numerous,  and  are  partly  epithelial  or 
granular,  and  partly  hyaline  or  waxy.  The  usual  duration  of  the 
albuminuria  is  from  two  to  three  weeks,  and  casts  are  discharged 
for  about  a  month. 

Dropsy  is  a  common  result  of  scarlatinal  nephritis.  It  usually 
shows  itself  as  anasarca,  when  desquamation  apparently  ceases ; 
less  frequently  as  an  effusion  into  the  serous  sacs  (ascites,  hydro- 
thorax,  hydro-pericardium,  hydrocephalus),  or  as  oedema  of  the 
lungs  and  glottis,  or  as  a  general  dropsy.  It  is  right  to  mention 
that  dropsy  may  also  be  present  without  albuminuria,  and  not  due 
to  any  obvious  cause,  so  far  as  the  kidneys  are  concerned.  It 
sometimes  even  occurs  without  marked  anaemia. 

M 


178  SCARLATINA. 

Inflammations  of  the  serous  membranes,  with  sero-plastic  or 
purulent  exudation,  occur  now  and  then.  They  are  independent 
of  the  kidney  affection,  although  often  observed  during  its  course. 
Pleuritis  is  the  most  common  of  these  inflammations ;  meningitis, 
peritonitis,  and  pericarditis,  occur  less  frequently. 

Inflammations  of  the  synovial  membranes  of  the  joints  are 
usually  met  with  just  when  desquamation  is  beginning,  but  may 
occur  at  any  other  period.  They  constitute  what  is  known  as 
scarlatinal  rheumatism.  The  condition  presents  itself  either  as  a 
more  or  less  intense  synovitis  acuta  with  serous  effusion,  or  as  a 
suppurative  arthritis,  terminating  in  ostitis  and  periostitis,  caries 
and  necrosis,  or  pyaemia  and  death.  Scarlatinal  rheumatism  may 
also  be  accompanied  by  peri-  or  endocarditis. 

The  heart  muscle  suffers  severely,  especially  from  the  hyper- 
pyrexia which  accompanies  the  severer  forms  of  scarlet  fever.  Its 
fibres  are  the  seat  of  an  acute  molecular  disintegration  or  of  a  more 
chronic  fatty  degeneration,  the  result  of  an  acute  parenchymatous 
myocarditis.  At  the  close  of  the  first  volume  of  his  "  Lectures  on 
Children's  Diseases,"  translated  for  the  New  Sydenham  Society  in 
1889,  by  Dr.  John  Thomson,  Professor  E.  Henoch,  of  the  Univer- 
sity of  Berlin,  speaks  of  "  the  fatty  albuminous  degeneration  of  the 
heart  muscle  which  occurs  pretty  often  after  acute  infectious 
disease,  especially  scarlet  fever,  diphtheria,  and  typhoid,  and  clini- 
cally gives  rise  to  no  symptoms,  except,  perhaps,  those  of  cardiac 
debility."     (Page  491.) 

In  the  second  volume  of  the  "  Cyclopaedia  of  the  Diseases  of 
Children" a  there  is  a  short,  but  interesting,  article  on  "Acute 
Parenchymatous  Myocarditis,"  from  the  pen  of  Dr.  J.  Mitchell 
Bruce,  Physician  and  Lecturer  on  Therapeutics  at  the  Charing 
Cross  Hospital,  London.  This  article  seems  to  me  to  throw  much 
light  on  the  aetiology  of  the  anginal  attacks  of  acute  febrile  dis- 
orders. Under  the  names  of  "  acute  parenchymatous  degenera- 
tion," "albuminous  degeneration,"  "febrile  softening  of  the 
heart,"  "infectious  myocarditis,"  Dr.  Bruce  says  that  from  time  to 

a  Edited  by  Dr.  JohnM.  Keating,  of  Philadelphia,  and  published  by  Messrs. 
J.  B.  Lippincott  and  Company,  of  the  same  city. 


SCARLATINA.  179 

time  has  been  described  a  kind  of  acute  change  in  the  muscular 
tissue  of  the  heart,  which  occurs  in  acute  febrile  and  infective 
diseases.  The  opinions  of  pathologists  as  to  the  nature  of  this 
disease  have  long  been,  and  are  still,  conflicting,  some  maintaining 
that  it  is  truly  inflammatory,  others  that  it  is  degenerative  only. 

"Parenchymatous  myocarditis"  is  the  result  of  acute  febrile  and 
infective  processes,  such  as  scarlatina,  diphtheria,  variola,  typhus, 
typhoid,  and  relapsing  fevers,  septicaemia  and  pyaemia,  more  rarely 
measles.  The  condition  may  be  set  up  during  the  later,  as  well  as 
in  the  earlier,  stages  of  these  diseases,  or  even  during  convalescence. 
In  it  the  heart  is  sometimes  distinctly  dilated ;  the  myocardium  is 
of  a  dirty  grayish  red  or  grayish  yellow  colour,  with  occasional 
extravasations  ;  its  consistence  is  soft ;  its  substance  is  lax,  flabby, 
and  friable.  Thrombi  may  be  found  in  the  ventricles.  Microscopi- 
cally, the  muscular  fibres  are  swollen,  their  striation  is  more  or 
less  lost  and  replaced  by  granular  (albuminous)  and  fatty  molecules  ; 
occasionally  they  undergo  waxy  degeneration  (Zenker).  Along 
with  these  evidences  of  degeneration,  there  are  found  certain  appear- 
ances which  suggest  regeneration.  Lastly,  the  blood-vessels  are 
dilated  and  the  seat  of  thrombosis,  with  cbliterative  endarteritis 
of  the  arterioles. 

Dr.  Bruce  points  out  that  the  pathological  connection  between 
this  acute  parenchymatous  change  and  its  cause  is  still  unsettled. 
It  may  be  the'  result  of  the  specific  action  of  the  several  poisons, 
or  of  the  pyrexia,  or  of  both,  on  the.  protoplasm.  It  is  closely 
related  to  fatty  degeneration  of  the  heart — indeed,  if  the  destruc- 
tive part  of  the  process  be  in  excess,  it  rapidly  proceeds  to  fatty  dege- 
neration, which  then  covers,  or  takes  the  place  of,  the  other  changes. 
As  regards  the  symptoms,  cardiac  failure  is  the  chief  evidence 
of  this  condition  of  the  myocardium. 

Diagnosis.  —We  have  to  distinguish  Scarlatina  from  Erythema, 
Smallpox,  Measles,  Rotheln,  Erysipelas,  Tonsillitis,  Diphtheria, 
and  Acute  Rheumatism. 

1.  Erythema  is  distinguished  by  the  fact  of  its  limited  distribu- 
tion— being  absent  from  the  neck  and  extremities,  and  by  its  irregular 
mode  of  spreading.  The  fever  is  slight.  There  is  no  sore  throat,  or 
swelling  of  the  cervical  glands,  or  kidney  affection,  or  desquamation. 


180  SCARLATINA. 

2.  It  is  only  at  the  beginning  of  an  attack  of  Smallpox  that  an 
error  of  diagnosis  could  be  committed.  The  adventitious  prodromal 
rash  of  smallpox  sometimes  closely  resembles  scarlatina,  and  the 
throat  also  may  be  sore.  In  arriving  at  a  diagnosis,  bear  in  mind 
the  prevailing  epidemic,  note  the  pulse-rate  and  temperature, 
examine  the  throat  and  cervical  glands,  and  watch  the  case  closely. 

3.  Scarlatina  is  distinguished  from  Measles  by  the  early  appear- 
ance of  the  rash,  the  absence  of  coughing  and  sneezing,  and  the 
character  of  the  fever.  In  measles — the  early  angina,  the  strawberry 
tongue,  and  the  glandular  swellings  of  scarlet  fever  are  wanting. 

4.  The  diagnosis  between  Scarlatina  and  Rotheln  is  often  most 
difficult.  We  must  be  guided  by  the  prevailing  epidemic,  the  short 
duration  of  the  rash,  which  shows  on  the  face  also,  and  of  the  fever 
in  Rotheln,  the  trifling  angina,  and  the  comparatively  slow  pulse  of 
that  disease,  in  which  also  the  kidney  affection  and  other  complica- 
tions of  scarlatina  are  wanting. 

5.  In  Erysipelas,  which,  by  the  way,  is  often  accompanied  by 
sore  throat,  the  rash  is  localised  and  not  punctate,  the  surface  is 
smooth,  there  is  marked  oedema  of  the  connective  tissue,  and  vesicles 
or  bullae  may  form.  In  scarlatina,  desquamation  may  occur  in 
places  where  there  has  been  no  antecedent  eruption ;  in  erysipelas 
this  is  never  the  case. 

6.  Acute  Tonsillitis,  Cynanche  tonsillaris,  or  Quinsy,  with  its 
high  temperature,  swollen  tonsils,  cedeinatous  uvula,  and  plum- 
coloured  fauces  is  not  infrequently  confounded  with  scarlatina. 
The  diagnosis  depends  on  the  history  of  exposure  to  infection  or 
otherwise,  and  the  absence  of  the  vomiting,  the  rash,  and  the  albumin- 
uria of  scarlatina.  Generally  also  one  tonsil  is  more  engaged  than 
the  other  in  tonsillitis,  whereas  the  scarlatinal  affection  is  bilateral. 

7.  In  a  case,  which  seems  to  be  one  of  primary  Diphtheria,  a 
careful  search  should  be  made  for  the  ill-developed  rash  of  scarlet 
fever,  and  regard  should  be  had  to  the  occurrence  of  other  cases  of 
the  latter  disease  in  the  immediate  neighbourhood  of  the  patient. 

8.  Acute  Kheumatism,  although  often  accompanied  by  sore 
throat  and  by  accidental  papular  or  miliary  eruptions,  is  distin- 
guished by  usually  attacking  adolescents  and  adults  rather  than 


SCARLATINA.  181 

children,  by  its  profuse  acid  and  sour-smelling  perspirations,  by  the 
absence  of  the  strawberry  tongue,  glandular  swellings,  and  renal 
complications  of  scarlatina,  and  by  its  whole  course. 

Prognosis. — This  is  uncertain  under  all  circumstances,  for 
scarlet  fever  is  one  of  the  most  treacherous  of  maladies,  and  therefore 
the  opinion  should  always  be  guarded  no  matter  how  mild  the  attack 
may  seem  to  be.  Mayr  wrote :  "  That  scarlatina,  even  in  the  mildest 
form,  is  never  a  trifling  complaint,  is  a  maxim  which  has  been  only 
too  fully  verified  by  many  sad  cases."  a  Sydenham's  opinion  as  to 
the  benign  character  of  the  disease  has  already  been  quoted — u  hoc 
morbi  nomen ;"  but  Loschner  some  forty  years  ago  used  an  equally 
epigrammatic  and  a  truer  phrase,  when  he  said,  "  I  have  never  seen 
a  benign  epidemic."  The  mortality  very  frequently  reaches 
between  13  and  18  per  cent.;  but  in  not  a  few  outbreaks  it 
is  as  high  as  25  per  cent.,  or  may  reach  even  to  30  and  40 
per  cent.  Age  influences  the  death-rate  to  a  great  degree.  It  is, 
on  the  average,  20  per  cent,  among  children  under  5  years.  So 
also  does  social  status,  but  to  a  far  less  extent.  Family  idiosyn- 
crasy plays  an  important  part  in  determining  the  mortality  from 
scarlet  fever.  Even  in  a  mild  epidemic,  a  family  may  here  and 
there  be  decimated,  the  disease  seeming  to  act  as  a  deadly  poison 
in  certain  households.  As  to  adult  cases,  the  mortality  is  highest 
among  pregnant  and  puerperal  women  and  invalids. 

Unfavourable  Signs  in  a  case  are :  Hyperpyrexia,  dyspnoea, 
extreme  rapidity  and  feebleness  of  the  pulse,  early  collapse,  badly 
developed  and  dark-coloured  rashes,  persistent  vomiting  and  diar- 
rhoea, delirium  or  coma,  sloughing  of  the  fauces  (angina  ganora?- 

nosa),  diphtheria,  purulent  arthritis,  and  other  severe  complications 

especially  nephritis  with  anuria,  and  diffuse  cellulitis  of  the  neck. 
Death  occurs,  according  to  Hebra,  from — 

(1.)  Dissolution  of  the  Blood. 

(2.)  Paralysis  of  the  Nervous  Centres  (Ataxia). 

(3.)  Suffocation,  from  (Edema  of  the  Glottis. 

(4.)  Pyaemia. 

(5.)  Renal  Disease. 

a  Hebra.     Diseases  of  the  Skin.    New  SyA  Soc.     1866.     VoL  I.,  page  213. 


182 


CHAPTER  XIX. 
The  Teeatment  of  Scarlatina. 

Prophylaxis  not  so  difficult  of  attainment  as  in  the  case  of  Measles. — Sug- 
gested prophylaxis  by  drugs  not  reliable. —Effectual  prophylaxis  consists  in 
Isolation. —  Curative  Treatment  :  no  antidote  yet  discovered.— Biniodide  of 
Mercury  (Illingworth). — Treatment  mnst  be  largely  symptomatic. — Treatment 
of  Scarlatina  simplex  :  expectant.  —  Hebra's  recommendations. — Gnaiacum 
and  Ozonic  Ether  Test  for  Blood-pigment  in  Urine. — Treatment  of  Scarla- 
tina ANGINOSA  :  cold  water  treatment,  quinine,  ice,  cold  compresses  to  neck, 
drugs. ^Treatment  of  Scarlatina  maligna  :  combat  ataxic  symptoms  ;  in 
haemorrhage,  use  local  and  general  astringents. — Treatment  of  Complications 
and  SequeLjE  :  Diphtheria,  rheumatism,  acute  desquamative  nephritis,  ursemie 
convulsions,  pleuritis,  endocarditis,  bubonic  swellings,  diffuse  cellulitis,  pyaemia, 
acute  furuncular  diathesis,  diseases  of  the  ear,  conjunctivitis,  keratitis,  acute 
eczema,  chorta. 

I.  The  Prophylaxis  of  Scarlet  Fever  is  not  attended  with  the  vast 
difficulties  which  beset  the  attempt  to  control  the  spread  of  Measles. 
Although  it  would  be  going  too  far  to  deny  that  scarlatina  is 
infectious  in  the  stages  of  invasion  and  of  early  eruption,  yet  there 
can  be  little  doubt  that  the  poisonous  virus  is  shed  in  greater 
quantity  during  the  later  stages  of  the  disease,  in  the  discharges 
from  the  nose  and  throat,  in  the  motions  from  the  bowels,  most 
likely  in  the  urine,  but  above  all,  in  the  desquamated  cuticle. 
HAnce,  breathing  time  is  allowed  the  physician  in  which  to  plan 
and  eive  effect  to  precautionary  measures. 

Again,  the  early  appearance  of  the  rash  and  the  sore  throat 
establish  the  diagnosis  long  before  the  period  when  measles  declares 
itself — that  is,  on  the- fourth  or  fifth  day.  Time,  therefore,  is  not 
permitted  to  the  malady  in  which  to  run  riot  through  a  family  or 
household. 

In  speaking  of  the  Preventive  Treatment  of  Scarlatina,  I 
may  state  at  the  outset  that  all  known  drugs  are  without  avail. 
Godelle  vaunted  hydrochloric  acid  as  a  prophylactic ;  Giersing 
suggested  the  internal  administration  of  carbolic  acid  ;  Hufeland 


SCARLATINA.  183 

and  Hahnemann  ascribed  to  belladonna  a  protective  influence 
against  scarlatina,  and  I  have  often  known  this  drug  to  be  given 
for  such  a  purpose  by  orthodox  physicians.  But  all  in  vain.  Dr. 
W.  G.  Walford,  of  London,  states  that  out  of  nearly  100  children 
exposed  to  infection  and  to  whom  full  doses  of  liquor  arsenicalis 
were  given,  in  only  two  did  the  disease  develop.  Children  bear 
arsenic  well.  Walford  gives  from  1  to  3  or  4  minims  of  Fowler's 
solution,  according  to  the  child's  age,  thrice  daily.  He  combines 
with  the  dose  15  to  30  minims  of  sulphurous  acid  and  a  little 
syrup  of  red  poppy  (syrupus  rhceados,  B.  P.)a 

Notwithstanding  these  statements  I  am  of  opinion,  with  Mayr 
and  Hebra,  that  we  must  conclude  that  "  the  only  effectual 
prophylaxis  of  scarlatina  consists  in  isolating  the  patients  from 
those  who  are  unaffected  as  early  and  as  completely  as  possible." 
This  isolation  should  be  kept  up  until  desquamation  has  finally 
ceased.  Reference  may  be  made  to  Chapter  IV.  for  the  details 
which  should  be  followed  in  carrying  isolation,  disinfection,  and 
other  preventive  measures  into  effect. 

A  scarlatina  patient  may  go  home  or  rejoin  school,  provided  he 
and  his  clothes  have  been  thoroughly  disinfected,  in  not  less  than 
six  weeks  from  the  appearance  of  the  rash,  if  desquamation  has  com- 
pletely ceased,  and  there  is  no  complaint  or  sign  of  sore  throat  or 
of  discharge  from  the  nose  or  ears. 

II.  So  far,  we  have  not  succeeded  in  discovering  an  antidote  for 
the  virus  of  scarlatina — we  have  no  specific  remedy  for  it.  The 
biniodide  of  mercury,  if  given  early  in  frequent  doses,  is  stated  by 
Dr.  C.  R.  Illingworth,b  of  Accrington,  to  shorten  the  disease  and 
relieve  the  throat  affection.  He  advises  that  a  child  aged  between 
2  and  6  years  should  be  given  every  second  hour  10  minims  of 
solution  of  the  perchloride  of  mercury  with  half  a  grain  of  iodide 
of  potassium  in  a  drachm  of  water.  Dr.  Eustace  Smith  recom- 
mends the  addition  to  this  mixture  of  small  doses — say,  half  a 
grain — of  chlorate  of  potassium. 

The  term  "  Curative  Treatment "  must,  however,  be  taken  in  a 

tt  Lancet,  1882.     And  Brit.  Med.  Journ.,  1884. 
b  Brit.  Med.  Journ.,  1886. 


184  SCARLATINA. 

qualified  and  restricted  sense  to  express  the  measures  we  adopt  to 
help  the  patient  safely  through  his  illness.  The  treatment  must, 
in  a  word,  be  largely  symptomatic,  and  directed  mainly  against 
those  complications  and  sequelae  which  disturb  the  regular  progress 
of  the  disease. 

In  mild  scarlatina  simplex  we  may  adopt  an  expectant  treat- 
ment more  or  less  like  that  recommended  by  Hebra. 

1.  The  patient  should  keep  his  bed  throughout  his  illness  in  a 
fresh,  airy  room,  with  just  as  much  covering  over  him  as  will  pre- 
vent him  feeling  cold.  Feather  bed,  coverlets,  and  movable  screens, 
should  all  be  avoided. 

2.  The  patient  should  not  be  allowed  to  leave  his  bed  until,  for 
two  or  three  days  there  has  been  complete  absence  of  fever,  thirst 
has  disappeared,  the  skin  has  been  soft  and  perspiring,  and  the 
pulse  has  been  quiet.  On  getting  up,  a  flannel  or  Jaeger  suit  should 
be  worn. 

3.  About  the  end  of  the  third  week  the  patient  may  be  ordered 
to  take  a  tepid  bath  daily,  or  every  second  or  third  day,  according 
to  circumstances. 

4.  As  soon  as  desquamation  has  ceased  on  the  hands  and  feet, 
as  well  as  on  the  face  and  body — that  is,  in  the  fourth  week,  the 
patient  may  be  allowed  to  go  out  into  the  open  air — weather  per- 
mitting, and  unless  any  fresh  symptoms  should  arise  to  prevent  this. 

5.  Cool,  refreshing  drinks,  such  as  cold  spring  water,  lemonade, 
acidulated  water,  are  to  be  given  freely,  and  at  short  intervals. 

6.  The  diet  should  consist  of  weak  meat-broth,  chicken-broth, 
gruel,  milk  (peptonised,  or  mixed  with  aerated  water  or  lime 
water  in  varying  quantity),  oranges,  and  cooked  fruits. 

7.  The  patient's  hair  may  be  combed  every  day ;  his  face  and 
hands  should  be  washed  with  soap  and  water.  The  bed  and  body 
linen  may  be  changed  as  often  as  required.  Tepid  sponging  of 
the  whole  body  is  useful  and  most  refreshing.  It  may  be  practised 
once  or  twice  a  day. 

8.  The  urine  should  be  examined  daily.  With  a  view  of  antici- 
pating the  danger  of  acute  scarlatinal  nephritis,  it  will  be  well 
daily  to  use  the  test  for  haemoglobin  suggested  by  the  Collective 


SCARLATINA.  185 

Investigation  Committee  of  the  British  Medical  Association  in  their 
Report  on  Paroxysmal  Hemoglobinuria* — that  is,  the  guaiacum  and 
ozonic  ether  test.  With  this  the  urine  gives  the  blue  tint 
characteristic  of  blood-colouring  matter,  when  haemoglobin  is  pre- 
sent even  without  blood  corpuscles. 

This  test  is  best  performed  by  adding  to  about  a  drachm  of 
urine  in  a  test-tube  a  few  drops  of  fresh  tincture  of  guaiacum  and 
twenty  or  thirty  drops  of  ozonic  ether.  The  whole  is  to  be  well 
shaken  and  then  allowed  to  settle,  when  the  ozonic  ether  rises  to 
the  top,  holding  in  solution  the  red  colouring  matter  of  the  guaiacum 
tincture,  of — if  blood  or  its  colouring  matter  be  present — the  blue 
pigment  to  which  this  has  been  transformed.  In  applying  the  test, 
instead  of  using  ozonic  ether,  the  same  quantity  of  old  turpentine 
will  answer  equally  well.  The  best  plan  also  is  to  make  a  fresh 
solution  of  a  few  grains  of  guaiacum  resin  in  a  little  methylated 
spirit  before  each  experiment.  This  test  suffices,  when  a  spectro- 
scopic examination  cannot  conveniently  be  made,  to  establish  the 
diagnosis  of  hemoglobinuria,  even  before  renal  hemorrhage  (hema- 
turia) has  taken  place. 

The  hot  air  or  vapour  bath  may  be  used  if  albuminuria  is  pre- 
sent, and  during  desquamation  the  tepid  bath  will  be  found  both 
grateful  and  beneficial.  It  may  be  given  daily  and  followed  by  dry 
rubbing  and  inunction  with  oil  (Dahne,  1810),  fat  bacon,  or  suet 
(Schneemann,  of  Hanover,  and  Charles  West,  of  London).  In  my 
own  practice,  I  employ  a  weak  carbolised  oil  (1  to  2  per  cent.),  or 
soft  paraffin  (vaseline),  or  camphorated  oil  (linimentum  camphore, 
B.P.).  Louis  Starr1*  recommends  that  the  whole  surface,  including 
the  scalp,  should  be  anointed  daily  during  desquamation  with  an 
ointment  consisting  of  carbolic  acid,  20  grains,  thymol  10  grains, 
vaseline,  or  simple  ointment,  1  ounce.  The  patient,  after  the 
anointing,  should  be  put  into  a  warm  bath  for  five  minutes,  pro- 
tected from  cold,  and  then  removed  to  bed,  the  body  being  wiped 
dry  beneath  the  bedclothes. 

1  am  aware  that  the  practice  of  inunction  has  been  objected  to 

a  See  Brit.  Med  Journal,  Jan.  2fi,  1884.     P.  189. 
6  Archives  of  Pediatrics.     July,  1890.     Philadelphia. 


186  SCARLATINA. 

on  the  ground  that  it  interferes  with  the  free  action  of  the,  skin, 
but  this  objection  is  merely  theoretical.  I  am  satisfied  that  to 
keep  the  skin  smooth,  moist,  and  pliable  in  scarlatina  is  essential, 
and  this  indication  is  met  by  inunction  or  anointing.  The  other 
advantages  of  the  practice  are— as  regards  the  patient,  relief  from 
itching  and  general  discomfort,  reduction  of  surface  temperature, 
protection  from  cold,  lessened  risk  of  kidney  congestion  owing  to 
the  free  action  of  the  skin.  From  a  prophylactic  point  of  view, 
the  fixing  of  the  infectious  scales  of  the  epidermis  by  inunction  is 
a  consideration  of  the  first  importance. 

9.  Scarlatina  is  a  great  blood-destroyer,  and  in  convalescence 
iron  will  be  required,  as  well  as  change  of  air  to  the  mountain 
slope  or  to  the  seaside. 

In  Scarlatina  anginosa  additional  treatment  to  the  foregoing 
will  be  required.  With  the  object  of  reducing  the  excessive  fever 
(hyperpyrexia)  which  so  frequently  accompanies  this  variety  of 
scarlet  fever,  the  cold-water  treatment  described  in  Chapter  V.  (see 
pages  53,  et  seq.)  should  be  carried  out.  Quinine  also  may  be  given 
freely  with  a  twofold  object — first,  as  an  efficient  antipyretic, 
secondly  as  an  equally  useful  antiseptic.  There  is  scarcely  any  form 
of  "  sore-throat"  over  which  quinine  does  not  exercise  a  more  or  less 
specific  action.  Again,  the  constant  swallowing  of  fragments  of 
ice  is  both  grateful  to  the  patient  and  effectual.  Cold  compresses 
of  lint  moistened  with  water  and  glycerine  should  be  wrapped 
round  the  throat.  The  nostrils,  mouth,  and  pharynx  should  be 
frequently  washed  or  sprayed  with  chlorine  water  or  warm  water 
containing  some  common  salt,  or  chlorate  of  potassium,  or  per- 
manganate of  potassium  (15  grains  to  the  ounce),  or  sulphurous 
acid  (I  in  8)  or  carbolic  acid  and  glycerine.  In  the  case  of  the 
mouth  and  pharynx,  these  remedies  may  also  be  used  in  the  form  of 
a  disinfecting,  antiseptic,  and  deodorising  gargle.  The  following 
formula  for  a  guaiacum  gargle  is  copied  from  the  Pharmaceutical 
Record,  January  5,  1891 : — 

$.  Tinct.  Guaiaci  Ammoniati ; 

Tinct.  Cinchonas  Composite,  aa  5SS  ; 
Potassii  Chloratis,  gr.  60  ; 


SCARLATINA.  1S7 

Mellis  Purissimi,  Jss ; 

Pulv.  Gurami  Acacia;,  gr.  GO  ; 

Aquae,  §iiss. 

M.  ft.  gargarisma.  Signa  :  To  be  used  as  a  gargle,  and  a  tea- 
spoonful  may  be  swallowed  every  second  hour. 

Caustics  of  all  kinds,  in  my  opinion,  had  best  be  avoided  in 
scarlatinal  sore-throat.  It  is,  however,  right  to  mention  that 
Trousseau  recommends  cauterisation  with  equal  parts  of  strung 
hydrochloric  acid  and  honey.  He,  no  doubt,  advises  caution  in 
the  use  of  the  remedy,  which — if  awkwardly  applied — might  cause 
spasm  of  the  glottis. 

Among  drugs  other  than  quinine  which  are  likely  to  be  of  use 
in  this  serious  affection,  the  ferric  chloride,  sulpho-carbolates,  hypo- 
sulphite of  sodium,  guaiacum,  and  salicylate  of  sodium  may  parti- 
cularly be  noticed.  The  perchloride  of  iron  may  be  given  with 
advantage  in  comhination  with  chlorate  of  potassium  and  quinine. 
In  America,  a  combination  of  boric  acid  and  iron  is,  according  to 
Fenwick,  a  favourite  remedy.  He  gives  this  formula : — Boric  acid, 
30  grains;  chlorate  of  potassium,  120  grains;  tincture  of  ferric 
chloride,  2  drachms  ;  glycerine,  one  ounce  ;  syrup,  one  ounce  ;  water, 
2  ounces.  One  teaspoonful  every  second  hour  for  a  child  of  five 
years.  Lastly,  a  moderate — sometimes,  a  free — allowance  of  stimu- 
lants is  necessary. 

The  treatment  of  scarlatina  maligna  is  too  often  of  no  avail — 
the  patient  dying  poisoned  in  a  few  hours  or  days.  It  is  our  duty, 
however,  to  combat  ataxic  symptoms  by  the  free  administration 
of  food  and  stimulants  and  by  such  remedies  as  carbonate  of 
ammonia,  quinine,  bark,  iron,  camphor,  and  musk.  "Derivation 
to  the  surface " — more  particularly  if  the  rash  fails  to  appear  or 
is  badly  developed — may  prove  of  use.  Wrapping  the  lower  limbs 
and  body  in  flannels  or  cloths  wrung  out  of  mustard  and  hot  water 
is  often  effectual,  and  I  have  myself  practised  the  method  with 
success.  Wunderlich  recommends  the  warm,  of  hot,  bath.  Thomas 
speaks  highly  of  the  cold  pack  and  cold  affusion  followed  by  warm 
wrappings.  Max.  Langenbeck  has  adopted  with  good  results  the 
use  of  the  hot  flat-iron,  combined  with  a  mustard  bath  and.  subse- 


188  SCARLATINA. 

quent  warm  wrappings.  Blisters  have  been  applied,  but  to  my 
mind  this  is  a  doubtful  procedure,  regard  being  had  to  the  usual 
tender  age  of  the  patients  and  to  the  kidney  delicacy  which  so 
often  accompanies  the  disease.  Sloughing  too  would  very  likely 
follow  the  application  of  a  blister. 

In  the  hemorrhagic  variety  of  scarlatina  maligna  we  must 
resort  to  general  and  local  astringents,  such  as  ferric  chloride  in 
full  doses,  gallic  or  tannic  acid,  ergot,  hamamelis  (or  hazelinej, 
assisted  by  a  nutritious  diet  and  port  wine.  Owing  to  kidney 
delicacy,  turpentine  is  usually  contraindicated  in  scarlet  fever.  Ice, 
in  every  form  of  application  or  use,  is  an  invaluable  remedy. 

We  have  now  to  consider  the  treatment  of  the  complications 
and  sequelae  mentioned  in  Chapter  XVII. 

1.  Diphtheria. — The  awful  prostration  which  usually  accom- 
panies this  affection  must  be  combated  by  food,  wine,  diffusible 
stimulants,  bark,  and  quinine  or  iron.  Young  children,  as  a  rule, 
take  quinine  very  well  if  it  is  mixed  with  milk,  and  not  dissolved 
in  an  acid  medium,  as  it  is  too  much  the  fashion  to  prescribe  it. 
When  there  is  a  diphtheritic  exudation,  a  spray  should  be  used 
containing  glycerine  of  carbolic  acid  (1  in  8),  or  lime  water — the 
solvent  power  of  which  is  very  marked,  or  solution  of  mercuric 
chloride,  or  lactic  acid  (the  strong  acid,  1  drachm ;  glycerine,  1 
drachm ;  water,  14  drachms),  or  papain  (1  to  2  parts  in  10  each  of 
glycerine  and  water).  Fenwick  gives  this  formula  :  Carbolic  acid, 
1  drachm,  or  boric  acid,  3  drachms ;  "  liquor  potassae,"  1  drachm  ; 
chlorate  of  potassium,  2  drachms  ;  glycerine,  2  ounces  ;  lime  water, 
8  ounces — to  be  used  as  a  spray,  '"  when  the  exudation  is  foul, 
jagged,  and  of  a  dirty  brown  appearance."  At  the  London  Hos- 
pital, a  solution  of  sulphurous  acid  (one  part  to  two  or  three  of 
water)  is  frequently  used  as  a  spray.  Powders,  too,  may  be 
employed  with  an  insufflator,  such  as  salicylic  acid,  2  drachms  ; 
subnitrate  of  bismuth,  2  ounces  (Fenwick).  Oertel,  the  author  of 
the  monograph  on  "  Diphtheria  "  in  von  Ziemssen's  "  Cyclopaedia  of 
Practical  Medicine,"  highly  recommends  the  constant  inhalation 
of  steam  at  113°  to  122°  F.,  passed  into  the  mouth  through  a 
funnel. 


SCARLATINA.  189 

2.  The  rheumatic  affections  of  scarlatina  are  best  treated  like 
ordinary  acute  rheumatism  (u  rheumatic  fever ").  The  affected 
joints  should  be  packed  in  wadding,  or  cotton  wool,  and  bandaged ; 
while  salicylic  acid,  salicin,  salicylate  of  sodium,  or  salol  should  be 
given  internally  in  large  and  frequently  repeated  doses.  Should 
peri-  or  endo-carditis  occur,  much  relief  will  be  obtained  by  the 
application  of  a  small  blister  over  the  epigastrium  or  precordial 
region,  as  recommended  by  Dr.  Alex.  Harkin,  of  Belfast. 

3.  Acute  Desquamative  Nephritis. — Dr.  Austin  Flint  lays 
down  the  following  indications  for  treatment  in  acute  nephritis, 
including,  of  course,  the  condition  met  with  in  scarlet  fever — (1.) 
Diminution  of  the  intensity  of  the  renal  inflammation,  promotion 
of  resolution,  and  restoration  of  the  excretory  function  of  the 
kidneys  ;  (2.)  Diminution  or  removal  of  dropsical  effusion ;  (3.) 
Elimination  of  urea  through  the  skin  and  gastro-intestinal  mucous 
membrane,  if  uraemia  exists  or  is  threatened. 

These  indications  will  be  met  by  adopting  the  line  of  treatment 
here  sketched  out. 

The  patient  should  remain  in  bed,  wrapped  in  a  blanket,  warm 
but  not  overwhelmed  with  bed-clothes  ;  clad  in  a  long  flannel  night- 
dress from  head  to  foot.  He  should  be  placed  on  a  mild  unstimulat- 
ing  diet  of  milk,  skimmed  or  in  the  form  of  buttermilk,  farinaceous 
food,  and  light  broths  (veal,  mutton,  chicken,  in  moderation),  all 
highly  nitrogenous  foods,  such  as  eggs,  butcher's  meat,  and  strong 
beef  tea  being  avoided.  His  thirst  should  be  relieved  by  copious 
draughts  of  cold  water  or  of  one  of  the  mineral  effervescing  waters 
which  will  safely  increase  pressure  in  the  glomeruli,  so  that  an  aug- 
mented transudation  may  wash  away  coagula  from  the  tubules  of 
the  kidney.  Dry  cupping,  followed  by  poulticing  over  the  kidneys, 
will  almost  certainly  do  good,  and  if  the  patient  is  robust  and  at 
the  same  time  in  much  pain,  local  depletion  by  leeching  or  wet 
cupping  over  the  loins  may  be  practised  with  benefit.  Even  vene- 
section may  be  practised  in  a  fairly  strong  subject  (Thomas  and 
Romberg). 

The  bowels  should  be  kept  open  by  hydragogue  cathartics,  like 
jalap,  bitartrate  of  potassium,  30  grains,  with  a  drachm  of  honey 


190  SCARLATINA. 

or  treacle,  scammony,  elaterin  (?),  senna,  and  colocynth — more 
particularly  if  dropsical  symptoms  have  superveued. 

All  stimulating  diuretics  must,  however,  be  shunned,  for  they 
only  increase  renal  hyperemia.  In  this  stage,  much  benefit 
will  be  derived  from  hot  air,  vapour,  or  even  warm  water  baths. 
The  hot  air  bath  should  not  be  prolonged  beyond  twenty  minutes. 
It  may  easily  be  improvised,  as  suggested  by  Dr.  Saundby,  by 
setting  a  spirit  lamp  carefully  under  a  stool  or  cradle  in  the 
bed,  if  one  of  the  cheap  tin  lamps  sold  for  the  purpose  is  not 
available. 

The  "  wet-pack "  already  described  may  also  be  used  with 
advantage  to  promote  elimination  through  the  skin.  If  uremic 
convulsions  supervene,  a  full  dose  of  sulphate  of  magnesium  (Epsom 
salts)  well  diluted,  or  a  bolus  of  calomel  and  jalap,  may  be  admin- 
istered, although  mercurials  should,  as  a  rule,  be  avoided  in  this 
affection — certain  it  is,  that  a  patient  in  nephritis  is  very  suscep- 
tible to  the  influence  of  mercury,  and  even  one  dose  of  calomel 
may  cause  salivation.  For  the  relief  of  convulsions,  also,  the 
temples  may  be  dry-cupped  or  leeched,  and  Trousseau's  plan  of 
compressing  the  common  carotid  artery  in  the  neck  on  the  side 
opposite  to  that  affected  by  the  convulsions  may  be  tried.  Com- 
pression may,  indeed,  be  practised  during  fifteen  minutes  on  each 
side  of  the  neck  alternately.  Other  means  of  relief  are :  a  com- 
bination of  chloral  hydrate  with  one  or  other  of  the  bromides,  or 
inhalations  of  chloroform  ;  or  the  nitrites — trinitrin  (nitro-glycerine), 
nitrite  of  sodium,  nitrite  of  amyl ;  or  citrate  of  caffein  or  theobromo- 
sodio-salicylate  (Diuretin) ;  or  an  enema  of  black  coffee  (cafe 
noir).  To  prevent  uraemia  Frerichs  recommends  benzoic  acid  in 
doses  of  from  three  to  fifteen  grains,  or  more,  according  to  age, 
either  in  pill  or  as  a  soluble  benzoate.  Four  grains  may  be  made 
up  into  a  pill  with  a  minim  of  glycerine  or  a  grain  of  Canada 
balsam ;  or  ten  grains  of  the  benzoate  of  sodium,  with  ten  minims 
of  tincture  of  digitalis  may  be  given  in  an  ounce  of  infusion  of 
gentian  to  an  adult  thrice  a  day  (Saundby). 

Pilocarpin  (^  gr.  to  ^o  gr-  every  six  hours,  or  ^  g1*-  SUD_ 
cutaneously,    for   a   child   live   years    old)    is   mentioned   by  Dr. 


SCARLATTN'A.  191 

Fenwick,  as  recommended  in  American  practice.  It  has  been  used 
in  this  country  also  for  many  years,  but  requires  great  caution  in 
its  administration. 

In  convalescence  the  patient  should  wear  woollen  clothing  day 
and  night,  and  in  all  seasons.  The  "Jaeger  system"  is  both 
popular  and  efficient.  In  this  stage  of  the  complaint  iron  and 
quinine  are  the  most  useful  drugs,  and  albuminous  food  should  be 
given  once  all  evidence  of  kidney  inflammation  has  passed  away. 

4.  For  the  relief  of  pleuritis  and  other  serous  inflammations, 
the  thorough  application  of  cold  is  recommended  by  Thomas,  to 
prevent  excessive  exudation.  Should  effusion  proceed  rapidly  in 
pleuritis,  paracentesis  thoracis  (thoracentesis)  must  be  practised. 
Endocarditis  is  best  controlled  by  absolute  rest,  the  continuous 
application  of  cold  to  the  precordial  region,  and  digitalis,  conval- 
laria,  or  strophantus  with  nux  vomica  internally. 

5.  Bubonic  swellings  may  be  treated  by  diligent  poulticing 
and  painting  with  iodised  glycerine.  In  the  later  stages,  chloride 
of  calcium,  cod  liver  oil,  iodide  of  iron,  and  saccharated  solution  of 
lime,  are  all  well  worth  a  trial.  In  the  diffuse  cellulitis  of  the 
neck,  Mr.  Croly,  in  the  paper  referred  to  already,  strongly  advo- 
cates early,  deep,  and  free  incisions,  as  recommended  by  the  late 
Mr.  W.  H.  Porter,  Surgeon  to  the  Meath  Hospital.  Only  in  young 
children  is  this  practice  open  to  question. 

6.  The  treatment  of  pyaemia,  and  of  the  "acute  furuncular 
diathesis,"  of  which  Trousseau  speaks  in  the  case  of  smallpox,  has 
already  been  discussed  when  speaking  of  that  disease. 

7.  The  diseases  of  the  ear  in  scarlatina  require  early  and  skilled 
attention,  if  their  dangerous  results  are  to  be  avoided.  Wendt 
advises  that  both  as  a  preventive  and  as  a  curative  measure  the 
secretions  should  be  removed  from  the  nostrils,  posterior  nares, 
pharynx,  throat,  and  even  from  the  proximal  portion  of  the 
Eustachian  tubes  by  douches  and  antiseptic  or  detergent  gargles. 
The  external  auditory  meatus  should  be  kept  clean  and  free  by 
gentle  syringing.  Air  should  be  forced  into  the  middle  ear  from 
time  to  time,  of  course  not  by  means  of  the  catheter.  If  intense 
pain  in  the  ear  is  complained  of,  leeching — even  the  application  of 


192  SCARLATINA. 

a  single  leech  sometimes — gives  great  relief,  followed  by  poulticing. 
The  bathing  treatment  of  severe  scarlatina  need  not  be  interrupted, 
provided  the  auditory  meatus  is  plugged  with  oiled  cotton  during 
the  bath. 

8.  Conjunctivitis  is  relieved  easily  and  effectually  by  water- 
dressings  ;  keratitis,  by  the  application  of  cold  and  dilatationof 
the  pupil  by  atropin.  If  the  cornea  threatens  to  slough,  it  should 
be  punctured  by  a  skilled  hand. 

9.  An  ointment  of  salicylic  acid  (10  grains  to  the  ounce)  often 
acts  almost  specifically  in  the  acute  eczema  of  children,  such  as 
follows  scarlet  fever.  Or  the  paste  recommended  by  Dr.  Charles 
Szadek  may  be  used,  namely,  salicylic  acid,  30  grains  ;  vaseline, 
half  an  ounce;  oxide  of  zinc  and  pure  starch,  of  each  360  grains. 

10.  In  chorea,  tonics  such  as  the  scale  preparations  of  iron, 
quinine,  valerianate  of  zinc,  and  so  on,  together  with  change  of  air 
and  scene,  will  prove  beneficial. 


Note. — The  most  recent  contribution  to  the  literature  of  the 
Bacteriology  of  Scarlatina  is  a  communication  by  Dr.  H.  Kurth, 
Konigl.  preuss.  Stabsarzt,  entitled  : — "  Ueber  die  Unterscheidung 
der  Streptokokken  und  iiber  das  Vorkommen  derselben,  insbesondere 
des  Streptococcus  conglomeratus,  bei  Scharlach."  ("  On  the  differ- 
ential diagnosis  of  the  Streptococci,  and  on  their  occurrence, 
especially  that  of  the  Streptococcus  conglomeratus,  in  Scarlatina  "). 
Dr.  Kurth's  monograph  was  published  in  the  seventh  volume,  second 
part,  of  the  "Arbeiten  aus  dem  Kaiserlichen  Gesundheitsamte," 
Berlin,  1891. 


193 


CHAPTER  XX. 

ROTHELN,    OR   EPIDEMIC    ROSE   RASH. 

Nomenclature. — Definition. — ^Etiology  (historical  sketch). — Clinical  His- 
tory :  Incubation,  invasion,  eruption,  desquamation. — Temperature. — Com- 
plications and  Sequelae. — Pathology.  — Diagnosis. — Claims  of  Rotheln  to  be 
considered  a  distinct  disease. — Prognosis  :  entirely  favourable. — Treatment. 

Nomenclature. — Rotheln.  Synon. —  Rubeola  (Orlow,  1758  ;a 
Hildenbrand,  and  even  Thomas  of  Leipzig  b)  ;  Rubeola  notha  (other 
German  writers) ;  Rubeola  sine  catarrho  ;  Rubella  (a  diminutive 
of  "Rubeola");  Roseola  Epidemica.  English,  German  Measles, 
Epidemic  Rose  Rash,  Epidemic  Roseola,  Bastard  Measles.  Fr. 
Roseole  (Trousseau)  ;  Exantheme  fugace  (synonym  mentioned  also 
by  Trousseau).  Germ.  Rotheln  (from  roth,  red).  Borsieri  described 
the  disease  under  the  name  Essera  Vogelii  (Trousseau). 

Definition. — A  specific  and  infectious  eruptive  fever,  distinct 
and  separate,  of  its  own  kind  (mi  generis) ;  neither  a  hybrid  of 
scarlet  fever  and  measles,  nor  a  modified  form  of  one  or  other  of 
those  diseases — Rotheln  breeds  true.  The  disease  begins  suddenly 
after  an  incubation  of  about  twelve  days,  with  ordinary  febrile 
symptoms  of  moderate  intensity.  The  rash  appears  on  the  first  or 
secoud  day.  There  are  slight  catarrhal  and  anginal  symptoms. 
Enlargement  and  induration  of  the  lymphatic  glands  in  the  occi- 
pital and  cervical  regions  is  a  constant  epipheuomenon.  The  febrile 
movement  is  brief,  and  recovery  is  generally  uninterrupted  and 
complete. 

iEtiology. — The  assumption  of  a  specific  roseola  is  based  chiefly 
on  the  fact  that  at  certain  times  epidemics  appear  in  which 
individual  cases  bear  a  cansal  relation  to  one  another.     Further, 

•  a  Be  Rubeolas  et  Morbillorum  Biscrim.  Progr.     Konigsb.     1758. 

h  Von  Ziemssen's  Cyclopcedia  of  the  Practice  of  Medicine.  Art.  Rubeola. 
Voh  I.,  p.  199.     1875. 

O 


194  ROTHELN. 

this  disease  affords  no  protection  against  either  measles  or  scar- 
latina, whereas  it  does  protect  an  individual  from  a  second  attack 
of  itself.  Lastly,  it  may  attack  those  who  have  lately  or  previously 
passed  through  either  measles  or  scarlatina. 

It  is  especially  a  disease  of  childhood,  but  may  occur  in  adults 
up  to  the  age  of  40.     Seitz  reports  a  case  in  a  woman  aged  73. 

There  is  reason  to  believe  that  epidemics  of  Rotheln  occur 
periodically  like  epidemics  of  measles.  In  his  account  of  the 
disease,  Thomas  mentions  two  such  epidemics  as  having  prevailed 
at  Leipzig  in  1868  and  1874.  In  1874,  also,  an  epidemic  was 
observed  in  New  York  by  Dr.  J.  Lewis  Smith.  The  first  British 
writer  on  the  disease  was  Dr.  Robert  Paterson,  of  Leith,  and  he 
adopted  the  German  term  Rotheln,  which  seems  to  be  the  most 
satisfactory  name,  for  it  precludes  any  possibility  of  confusion  in 
nomenclature.  Sir  William  Aitken  draws  a  distinction  between 
Roseola  and  Rubeola  or  Rotheln,  for  his  description  of  the  latter  im- 
presses the  reader  with  its  severity  compared  with  the  trivial  nature 
of  the  former.  Trousseau,a  however,  makes  no  such  distinction 
between  Roseola  and  Rubeola,  nor,  indeed,  does  Wunderlich,  who, 
in  common  with  German  writers  generally,  employs  Rubeola, 
Rubeola  notha,  and  Rotheln,  as  synonymous  terms. 

It  is  curious  to  compare  Sir  William  Aitkens'  description  of 
Rubeola  with  those  given  by  the  two  authors  named.  He  says :  b 
"  The  prognosis  requires  to  be  as  guarded  as  in  scarlatina  ;  for,  like 
scarlatina,  rubeola  is  often  an  extremely  and  rapidly  fatal  disorder." 
Trousseau  writes :  "  De  toutes  les  fievres  eruptives  la  ros^ole  est  la 
plus  b^nigne  :  jamais  elle  nepresente  de  gravite,  et  ton  jours  elle  se  ter- 
mina  spontanement  sans  que  le  m&lecin  ait  en  aucune  facon  besoin 
d'intervenir."  Wunderlich's  translator,  Dr.  Bathurst  Woodman, 
renders  that  author's  opinion  as  follows  :  "  Rubeola  (Rubeola  notha, 
Rotheln,  or  the  so-called  hybrid  between  measles  and  scarlatina, 
sometimes  called  Roseola  also)  does  not  necessarily  entail  any  fever  at 
all,  and  only  a  slight  transient  attack  before  and  during  the  eruption. 

a  Clinique  Medicate  de  V Hotel  Dieu  de  Paris.  Deuxieme  Edition.  1865. 
Tome  I.,  page  151. 

b  The  Science  and  Practice  of  Medicine.     Third  Edition.  Vol.  I.,  page  351, 


ROTHELN.  195 

The  elevations  of  temperature  are  generally  subfebrile,  or  at  the 
worst  moderately  febrile." 

Dr.  Hilton  Fagge  points  out,  in  his  "  Principles  and  Practice  of 
Medicine,"  that  a  precisely  similar  difference  of  opinion  as  to  the 
severity  of  Rotheln  is  shown  to  exist  when  one  compares  the  por- 
trait of  the  disease  drawn  by  Paterson,  Copland,  and  other  writers 
of  40  or  50  years  ago,  and  the  account  given  of  it  by  Thomas,  of 
Leipz;g,  in  von  Ziemssen's  "  Cyclopaedia  of  the  Practice  of  Medicine." 
The  result  of  this  difference  of  opinion  was  to  shake  Hilton  Faggc's 
belief  in  the  separate  identity  of  Rotheln.  Trousseau,  however, 
puts  the  matter  fairly  and  well  when  he  asserts  that  Rotheln  bears 
the  same  relation  to  measles  and  scarlatina  that  varicella,  or 
chickenpox,  does  to  smallpox.  This  is  equivalent  to  saying  that 
it  is  a  totally  distinct  disease.  In  a  Clinical  Lecture  on  Rotheln, 
delivered  at  the  Middlesex  Hospital  in  1874,  Dr.  Robert  Liveing, 
no  mean  authority  on  the  subject,  condemns  the  synonyms  "  hybrid 
measles,"  or  "hybrid  scarlatina"  assigned  to  this  exanthematic 
fever  as  "most  objectionable,  inasmuch  as  they  give  colour  to  the 
erroneous  notion  that  the  disease  is  a  combination  of  measles  with 
scarlatina.'" a 

Clinical  History : — 

I.  Stage  of  Incubation — To  the  Irish  Hospital  Gazette  for  June 
15,  1874,  I  communicated  a  series  of  three  cases  of  Rotheln  which 
had  come  under  my  notice  within  the  previous  year  or  so.  Of 
these  the  first  two  occurred  in  a  brother  and  sister,  the  latter  of 
whom  sickened  12  days  after  her  brother.  Dr.  Murchison,  speaking 
of  a  case,  says : b  ''  About  ten  or  fourteen  days  subsequently,  a 
second  child  in  the  same  family  had  a  similar  attack."  In  the 
New  York  outbreak  of  1874,  reported  by  Dr.  J.  Lewis  Smith,  the 
incubative  period  did  not  seem  to  be  uniform.  In  some  instances 
it  appeared  to  be  from  seven  to  ten  days,  and  in  others  from 
eighteen  to  twenty-two  days.  Thomas  assigns  to  this  sta°-e  a 
duration  of  from  2^  to  3  weeks. 

a  The  Lancet.     March  14,  1874.     Page  360. 
b  The  Lancet.     October  29,  1870.     Page  595. 


1 96  ROTHELN* 

II,  Stage  of  Invasion. — The  premonitory  symptoms  are  some- 
times absent  — or  very  badly  marked.  In  a  considerable  number 
of  the  cases  in  New  York  in  1874,  the  patients  were  not  known  to 
be  sick  until  the  rash  was  observed  covering  the  surface.  Usually, 
however,  the  initial  phenomena  of  a  feverish  attack  are  fairly  pro- 
nounced— the  patients  are  dull  and  languid,  and  complain  of  head- 
ache, chilliness,  general  discomfort,  loss  of  appetite,  thirst,  pains  in 
the  limbs,  vomiting  and  diarrhoea.  The  throat  is  injected,  but  the 
coryzal  symptoms  of  measles  are  absent  or  are  only  slightly  deve-, 
loped.  In  exceptional  cases  convulsions  may  occur.  Dr.,  Lewis 
Smith  met  with  clonic  convulsions  in  a  boy  of  8  years.  Nausea  is 
a  common  symptom. 

III.  Stage  of  Eruption. — In  a  few  hours  or  on  the  second  day  the 
rash  appears  in  different  parts  of  the  body,  thence  extending  to  the 
legs  the  next  day.  It  may  show  itself  first  upon  the  face  and  neck, 
or  down  the  back,  or  over  the  chest.  Most  frequently  it  resembles 
the  rash  of  measles  ;  sometimes  it  is  scarlatiniform  in  appearance, 
although  Thomas  denies  this.  The  compound  or  hybrid  eruption 
has  been  observed  by  Dr.  Kuttner,  of  Dresden.8,  Lewis  Smith  says 
that  the  rash  in  the  New  York  epidemic  resembled  more  that  of 
measles  than  of  any  other  eruptive  fever,  but  in  one  case,  a. boy  of 
three  and  a  half  years,  it  presented  over  the  trunk  very  much  the 
scarlatinous  appearance.  Dr.  Liveing  also  describes  the  rash  as 
consisting  "  of  small  rounded  collections  of  minute  red  papules, 
which  after  a  time  coalesce  and  form  larger  irregular  patches,  just 
as  in  measles,  but  with  apparently  less  tendency  to  become  of  a 
horse- shoe  or  crescentic  shape.  After  a  time  the  patches  may  all 
unite,  and  then  the  skin  becomes  to  the  naked  eye  of  a  uniform  red 
colour,  closely  resembling  that  in  scarlet  fever."  It  will  be  observed 
that  Liveing  speaks  of  "  papules,"  and  the  appearance  in  one  of 
my  cases  quite  bears  out  this  description  and  Sir  William  Aitken's 
remark,  that  "  the  eruptive  patches  are  felt  to  be  distinctly  elevated 
above  the  skin,  some  more  than  others,  and  always  greatest  in  the 
centre  of  the  patch."  L.  Smith  says  the  rash  "  disappeared  on 
pressure,  caused  a  little  roughness,  as  ascertained  by  carrying  the 

8  C'f.  Dublin  Hospital  Gazette.     Dec.  15th,  1858. 


KOTIIELNl  107 

fingers  over  the  surface,  and  faded  without  desquamation."  The 
slightly  raised  rose-coloured  spots  or  maculae  of  Rcitheln  vary  in 
size  from  a  mere  point  to  one-sixth  of  an  inch  in  diameter. 

On  the  other  hand  Trousseau  states  that  the  patches  of  roseola 
do  not  project  ahove  the  surface  of  the  skin  like  those  of  measles — 
"  Les  taches  rub^oliques  ne  sont  plus  en  effet  saillantes  comme  le  sont 
les  taches  morbilleuses."8.  All  writers  are  agreed  that  troublesome 
itching  accompanies  the  rash,  which  fades  gradually,  sometimes  (as 
in  one  of  my  cases)  leaving  dark  and  dirty,  or  yellowish  stains  like 
those  in  measles,  which  are  visible  for  five,  six,  or  more  days. 

Simultaneously  with  the  dermatitis,  there  is  a  mild  inflammation 
of  the  mucous  membranes  covering  the  buccal,  pharyngeal  and 
nasal  surfaces,  and  of  the  conjunctivae.  This  gives  rise  to  a  certain 
degree  of  sore-throat,  sneezing,  running  from  the  nose,  suffused, 
watery,  or  reddish  eyes,  with  slight  oedema  of  the  lids,  and  often  a 
muco-purulent  secretion  which,  drying,  glues  them  together, 
especially  in  the  mornings. 

Lastly,  allusion  must  be  made  to  an  almost  pathognomonic  sign 
of  Rbtheln,  and  this  is  enlargement  and  induration  of  the  lymph- 
glands,  particularly  those  on  the  mastoid  processes  and  behind 
the  sterno-mastoid  muscles,  and  those  of  the  posterior  chain  below 
the  occipital  protuberance.  Analogy  would  lead  us  to  infer  that 
the  bronchial  glands  share  in  this  pathological  change — a  point 
which  has  a  material  bearing,  as  I  hope  to  show,  on  the  prognosis. 

IV.  Stage  of  Desquamation. — There  is  but  little  "peeling"  in 
Rotheln.  Lewis  Smith  says  the  rash  "  faded  without  desquama- 
tion." In  one  of  my  cases  there  was  "slight  desquamation  on  the 
bridge  and  at  the  sides  of  the  nose ; "  in  another  case,  the  skin 
was  shed  in  large  flakes  as  in  scarlatina,  and  even  the  nails  came 
off. 

Temperature. — The  febrile  movement  is  usually  slight.     Wun- 

derlich's  opinion  on  this  point  has  been  quoted  above.b     Dr.  Edward 

Ellis  says :  "  The  temperature  in   my  own  experience,  has  been 

remarkably  low,  rarely  reaching  and   never  exceeding  100°  F. ; 

a  Clinique  Medicnle.     Tome  I.     1865. 

b  A  Practical  Manual  of  the  Diseases  of  Children.     Second  Edition.    Page  73. 


1 98  KOTHELN* 

sometimes  ranging  from  97°  F.  to  99°  F."  To  the  same  effect,  Dr. 
Lewis  Smith  observes :  "  The  febl'ile  movement  was  ordinarily 
mild,  the  pulse  in  ten  uncomplicated  cases  ranging  from  80  to  100, 
and  the  temperature  from  98£°  to  100°." 

In  my  own  three  cases  the  maximal  temperatures  noted  were 
102-4°,  98-2°,  and  99  8°  respectively. 

Complications  and  Sequelae  may  almost  be  said  not  to  exist  in 
Rotheln.  In  one  instance,  notwithstanding,  I  could  not  help 
regarding  an  attack  of  this  disease  as  the  starting  point  in  a  young 
barrister  of  chest  delicacy,  which  nearly  cost  him  his  life,  through 
profuse  and  repeated  hamioptyses.  Happily,  after  some  years  of 
invalid  life  he  completely  recovered.  The  occipital  glands  were 
much  enlarged  during  this  gentleman's  attack  of  Rotheln,  and  in 
the  light  of  his  subsequent  history  the  conviction  was  forced  upon 
me  that  a  similar  enlargement  of  the  bronchial  glands  had  been 
followed  by  caseation  and  even  tubercular  disease. 

At  all  events,  the  possibility  that  Roiheln  may  be  the  starting 
point  of  phthisis  pulmonalis  can  never  in  future  be  absent  from 
my  mind  when  culled  upon  to  attend  a  case  of  this  disease. 

Pathology. — This  topic  has  been  sufficiently  discussed  in  the 
preceding  remarks  on  the  aetiology  and  clinical  history  of  tlie 
affection.  There  is,  in  fact,  little  that  is  specific  in  the  Morbid 
Anatomy  of  Rotheln. 

Diagnosis. — "Writing in  1874,  Dr. Li veinga observes  : — "German 
measles  is  not  yet  fully  recognised  by  the  profession  in  this  country ; 
little  or  no  account  is  given  of  it  in  our  ordinary  text-books  on 
medicine,  and  its  name  does  not  find  a  place  in  the  '  Nomenclature 
of  Diseases,'  drawn  up  by  a  Committee  of  the  Royal  College  of 
Physicians.  Under  these  circumstances,  it  is  not  surprising  that 
errors  of  diagnosis  should  sometimes  bring  discredit  on  our  profes- 
sion." In  a  Clinical  Lecture  on  Rotheln,  also  delivered  at  the 
Middlesex  Hospital,  in  April,  1870,  the  late  Dr.  Charles  Murchison 
spoke  in  the  same  strain. b  After  describing  two  cases,  he  remarked  : 
"  The  ailment  from  which  these  patients  suffered  is  not  generally 

a  The  Lancet,  March  14,  1874,     Page  360. 
b  The  Lancet,  October  29,  1870.     Page  595. 


ROTHELN.  199 

recognised  as  a  distinct  disease ;  and  cases  of  it,  when  they  occur, 
are  apt  to  be  puzzling,  and  sometimes  to  get  the  medical  attendant 
into  trouble  from  his  inability  to  determine  their  real  nature.  Yet, 
on  the  whole,  they  are  not  very  rare." 

The  following  cases  will  exemplify  the  difficulties  which  arise 
in  connection  with  the  diagnosis  of  Rbtheln.  They  are  culled 
from  the  note-books  of  a  physician  of  much  skill  and  experience : — 
A  lad,  aged  seven,  showed  the  rash  of  measles  on  June  18,  1852. 
A  second  child,  a  girl,  aged  five  and  a-half,  had  the  rash  on 
June  29  ;  a  third,  a  girl,  aged  two,  on  June  30.  The  mother  of 
these  three  children  told  the  physician  that  the  boy  had  a  year 
before  an  attack  of  what  was  thought  to  be  "  spurious  measles," 
the  rash  more  vivid  than  on  the  present  occasion,  with  sore  throat 
and  followed  by  desquamation  of  cuticle.  He  did  not  appear  sick, 
was  not  confined  to  bed,  and  did  not  communicate  the  disease  to 
any  of  the  other  children. 

On  November  18,  1851,  the  same  physician  vaccinated  a  baby 
girl,  aged  three  months.  On  the  fifth  day,  the  eyes  watering,  an 
eruption  of  ''roseola"  came  out  and  spread  over  the  whole  body. 
It  was  very  evident  on  the  scalp  and  trunk,  was  attended  with  a 
good  deal  of  restlessness,  and  a  disinclination  to  take  the  breast. 
It  was  at  its  height  on  the  seventh  day,  and  nearly  gone  on  the 
eighth  day  after  vaccination,  in  no  way  retarding  the  progress  of 
the  vesicle. 

On  the  13th  of  the  following  month  an  eruption  like  measles 
came  out  on  the  baby's  sister,  aged  nearly  five  years.  She  passed 
through  her  attack  with  very  little  constitutional  disturbance 
and  without  much  cough  or  catarrh. 

On  July  20,  1854,  the  rash  of  genuine  measles  came  out  on  the 
aforesaid  baby,  then  aged  four  years.  She  had  taken  the  disease 
from  her  elder  brother,  aged  eight  years  and  nine  months,  who, 
after  three  or  four  days  of  "  off  and  on "  feverishness,  showed 
well-marked  catarrhal  symptoms  and  the  rash  of  measles  on  July 
8,  1854.  On  the  28th  the  measles  eruption  came  out  on  the  sister, 
who  had  been  infected  with  Rbtheln  in  1851,  and  who  was  now 
seven  and  a  half  years  of  age. 


200 


EOTHELN. 


In  the  three  cases  I  detailed  in  the  Irish  Hospital  Gazette,  the 
chief  points  of  diagnostic  interest  were — 

(1.)  The  trifling  degree  of  pyrexia  observed. 

(2.)  The  early  appearance  of  the  eruption — always  within  48 
hours. 

(3.)  The  presence  of  only  slight  hyperemia  of  the  fauces  without 
acute  inflammation  or  ulceration. 

(4.)  The  evidence  afforded  by  the  second  case  of  the  series  as  to 
the  infectious  nature  of  this  exanthem  and  as  to  the  length  of  its 
period  of  incubation. 

(5.)  The  changeable  character  of  the  eruption. 

Notwithstanding  the  formidable  account  of  this  disease  pre- 
sented to  us  by  Sir  William  Aitken,  the  balance  of  opinion  seems 
to  be  in  favour  of  its  comparatively  trivial  nature.  Rotheln, 
indeed,  may  be  said  to  derive  its  chief  importance  from  so  often 
and  sometimes  so  closely  resembling  measles  or  scarlatina. 

The  arguments  which  may  be  advanced  in  support  of  the  claim 
of  Rotheln  to  be  considered  a  distinct  disease  are  these : — 

1.  It  occurs  in  persons  who  may  already  have  had  either  measles 
or  scarlatina,  or  both  these  fevers. 

2.  It  does  not  protect  from  an  attack  of  either  of  these  diseases. 

3.  It  does  protect  from  itself,  just  as  measles  protects  from 
measles,  smallpox  from  smallpox,  scarlatina  from  scarlatina, 
Trousseau,  indeed,  does  not  hold  this  view,  for  he  says :  "  Une 
roseole  ante^cedente  ne  preserve  pas  de  nouvelles  attaques." 
Borsieri  went  still  further  when  he  wrote :  "  Qui  semel  Us  laboravit 
facile  iterum  pluriesque  prehenditur."  "  He  who  has  once  suffered 
from  it,  is  easily  attacked  by  it  again  and  again." 

4  It  can  propagate  itself — in  the  words  of  Dr.  R.  Liveing — 
"  the  seed,  as  a  gardener  would  say,  comes  up  true." 

5.  The  subfebrile  temperature  of  the  early  stage  at  once  tends 
to  preclude  the  possibility  of  scarlatina,  and  the  probability  of 
measles. 

6.  The  early  appearance  of  the  rash  distinguishes  it  from  that 
of  measles,  while  its  usually  "  measly  "  character  aids  the  diagnosis 
from  scarlatina.  .  ;        I.',:  -: 


ROTHELN.  201 

7.  The  anomalous  combination  of  the  coryzal  symptoms  of 
measles  with  the  sore-throat  of  mild  scarlatina,  should  excite 
suspicion  as  to  the  probable  presence  of  Rbtheln. 

8.  The  whole  subsequent  course  of  the  disease  and  of  its  eruption 
affords  grounds  for  a  differential  diagnosis. 

From  ordinary  Rose-rash  or  Roseola,  and  indeed  from  Erythema 
also,  Rbtheln  is  distinguished  by  its  pyrexia,  enlarged  glands,  and 
throat  symptoms. 

Prognosis. — From  the  close  resemblance  of  the  initial  symptoms 
and  eruptions,  sometimes  to  those  of  measles,  sometimes  to  those  of 
scarlatina,  the  diagnosis  of  Rbtheln  is  often,  as  we  have  seen,  a 
matter  of  considerable  difficulty.  Under  such  circumstances,  the 
early  prognosis  should  always  be  guarded.  It  is  far  better  to  have 
been  mistaken  in  our  diagnosis  in  assuming,  for  the  time  being, 
that  we  had  to  deal  with  either  measles  or  scarlatina,  than  to  have 
imperilled  the  lives  of  many  children  by  neglecting  to  isolate  the 
sick  from  the  healthy  in  due  time. 

Once  the  diagnosis  is  made,  we  may,  ill  most  cases,  pronounce 
an  entirely  favourable  opinion.  Let  us  bear  in  mind  at  the  same 
time  that  even  this  "  lightest  of  the  acute  exanthems  " — as  Thomas 
calls  it — may  occasion  grave  disturbances  or  even  death  in  a  delicate 
subject,  and  that  the  enlargement  of  the  lymph  glands  which  so 
constantly  accompanies  it  may  have  far-reaching  and  untoward 
effects  upon  the  patient's  health  and  constitution. 

Treatment. — A  case  of  Rotheln  should  be  treated  exactly  as  if 
it  was  one  of  simple  measles.  The  child  should  be  kept  in  bed 
while  fever  lasts,  protected  against  cold,  and  suitably  fed.  Tepid 
or  cool  sponging  will  relieve  itching.  Watch  should  be  kept  upon 
the  catarrh  of  the  pharynx  and  of  the  air-passages.  Warm  baths 
are  most  useful  in  convalescence.  In  a  word,  good  nursing  and 
sound  common  sense  alone  are  wanting  to  tide  a  patient  over  an 
attack. 


202 


CHAPTER    XXI. 
Erysipelas. 

Nomenclature. — Defi»ition. — ^Etiology. — Erysipelas  both  a  local  and  a 
specific  disease. — Medical  or  Idiopathic  and  Surgical  or  Traumatic  Erysi- 
pelas.— Predisposing  Causes  :  traumatism,  a  previous  attack,  sex,  age, 
climate,  season. — Exciting  Causes  :  contagion,  inoculation.  Doctrine  of  the 
Contagiousness  of  Erysipelas  not  proved. — Bacteriology  :  Streptococcus  Ery~ 
sipelatis  (Fehleisen). 

Nomenclature. — Erysipelas  (Greek — ipvcri7re\a<;,  Hippocrates, 
B.C.  430).  Synon. — St.  Anthony's  Fire  (Lot.  Ignis  Sacer).  In 
Scotland  it  is  called  the  "Rose."  Germ.  Rothlauf,  Rose,  Hautrose, 
Erysipelas.  Fr.  Erysipele,  Feu  Sacre,  Feu  de  Saint  Antoine, 
Mai  de  Saint  Antoine.  Ital.  Risipola,  Erisipela.  Span.  Erisipela. 
Dutch,  Roos,  St.  Antonie's  Vuur.  Swedish  and  Norwegian  or 
Danish,  Rosen. 

The  Etymology  of  the  word  "  Erysipelas  "  is  not  settled.  In  the 
the  Vet.  Med.  and  Aphorisms  of  Hippocrates  the  word  occurs  in  its 
Greek  dress  epvaiireka<i.  Liddell  and  Scott  derive  it  from  ipv9po<i, 
red,  and  treWa,  skin.  Billroth  substitutes  7reX.<z<?,  "  a  tumour  "  or 
"  swelling,"  for  7reX,\a ;  and  7re\o5  (pallidas)  is  also  erroneously 
suggested  as  the  root  of  the  second  portion  of  the  word.  Another 
fanciful  derivation  is  from  ipva),  I  draw,  7reXa?,  near. 

Definition. — An  acute,  specific  febrile  disease,  of  varying  course 
and  uncertain  duration,  undoubtedly  contagious  or  infectious, 
characterised  by  a  polytvpical  range  of  temperature  ;  but,  above  all, 
by  a  special  form  of  dermatitis,  with  sharpely-defined  redness  and 
swelling  of  the  skin.  This  spreads  indefinitely  by  the  lymphatics 
from  its  starting  point  in  a  breach  of  surface,  however  slight,  in 
the  skin  or  mucous  membrane,  through  which  the  specific  poison, 
virus,  or  contagium  of  the  disease,  gains  an  entrance  into  the  system 
from  without  (Inoculation). 


ERYSIPELAS.  2(>3 

etiology. — Erysipelas  is  certainly  to  be  regarded  as  a  specific 
disease,  because  it  depends  upon  the  entrance  into  the  system  of  a 
specific  micro-organism — the  Streptococcus  erysipelatis  of  Fehleisen. 
In  one  sense,  it  is  a  local  disease,  inasmuch  as  the  virus  settles 
upon  the  spot  which  is  afterwards  to  become  the  focus  of  the 
erysipelatous  inflammation — the  infection  of  the  blood,  and  therefore 
of  the  whole  system,  being  secondary.  In  this  respect  erysipelas 
is  precisely  analogous  to  diphtheria.  A  strong  argument  in  favour 
of  this  view  is  afforded  by  the  complete  want  of  symmetry  in  the 
distribution  of  the  skin  affectiou  which  is  so  constantly  observed. 
With  equal  propriety,  however,  erysipelas  is  classed  with  general 
diseases  of  specific  origin,  for  like  them  it  requires  a  certain 
incubative  period  for  the  development  of  its  constitutional  symp- 
toms. 

Dr.  J.  J.  Pringle a  well  observes  that  the  term  erysipelas  "  is, 
unfortunately,  applied  loosely  to  many  other  diseases  accompanied 
by  an  erythematous  blush  (simple  lymphangeiitis,  various  erythe- 
mata),  and  also  to  certain  conditions  of  phlegmonous  «and  diffuse 
cellular  inflammation,  which  may  complicate  erysipelas  but  are  due 
to  a  different  virus — viz.,  the  microbe  of  septicaemia." 

The  old  and  classical  division  of  erysipelas  into  Medical  and 
Surgical,  proposed  by  Borsieri  and  sanctioned  and  adopted  by  Sir 
Thomas  Watson,  Bart.,  is  purely  artificial,  and  being  useless  as 
well  as  unfounded  in  fact,  should  be  abandoned.  When  the  disease 
affected  the  head  and  face,  apart  from  surgical  injury,  it  was 
described  as  "Idiopathic"  or  "Medical  Erysipelas."  When  it 
attacked  the  limbs,  the  body,  or  even  the  head  after  injuries,  it 
was  dubbed  "  Traumatic  "  or  "  Surgical  Erysipelas." 

To  Trousseau  belongs  the  merit  of  pointing  out  the  unreality  of 
any  such  distinction.  So  long  ago  as  1856  Gublerb  showed  that 
facial,  or  the  so-called  "  Medical "  erysipelas,  was  only  a  propaga- 
tion of  the  disease  from  the  pharynx,  and  not  a  metastasis,  a 
theory  which  before  that  had   been  often  advanced.     Trousseau 

a  A  Dictionary  of  Practical  Medicine.     Edited  by  James  K.  Fowler,  M.A., 
M.D.     Art.  "Erysipelas."     London  :  J.  &  A.  Churchill.     1891. 
b  Memoiies  de  la  Societe  de  Biologic.     1856.     Page  40. 


204  ERYSIPELAS. 

adopted  Gubler's  view,  and  as  a  result  of  most  careful  clinical 
observations  maintained  that  the  so-called  idiopathic  or  medical 
erysipelas  had  almost  always  a  starting  point,  which  though  it  could 
not,  strictly  speaking,  be  called  a  wound,  was  at  least  a  lesion — a 
very  slight  lesion  it  might  be  in  some  cases,  such  as  a  scratch,  an 
eczema,  an  herpetic  ulceration,  an  inflammation  of  the  gum  from 
a  carious  tooth,  or  a  slight  abrasion  of  the  integuments  at  some 
point  on  the  face,  such  as  the  corner  of  the  eye,  the  nose,  the  lips, 
behind  the  ear,  or  on  the  hairy  scalp.8, 

Jn  these  views  Volkmann,b  B.  Kbnig,0  Hirsch,d  and  Zuelzer*5  all 
concur,  and  the  question  may  be  regarded  as  settled. 

Predisposing  Causes. — (1.)  It  follows  from  the  foregoing 
observations  that  we  are  to  regard  Traumatism  as  the  most 
powerful  predisposing  cause  of  erysipelas  in  the  abstract.  So 
frequently  has  the  disease  arisen  and  spread  in  the  wards  of 
surgical  hospitals,  that  the  name  "Erysipelas  nosocomiale"  has 
been  applied  to  it.  In  a  hospital  the  poison  of  erysipelas  ofien' 
clings  to  particular  wards,  and  even  to  particular  beds,  wiih 
extreme  obstinacy  (Hilton  Fagge.) 

(2.)  Although  classed  with  the  eruptive  fevers,  erysipelas  presents 
some  remarkable  points  of  contrast  to  the  other  diseases  included 
iu  this  category.  The  brief  period  of  invasion,  the  frequency  of 
relapse,  the  peculiarity  of  its  constantly  starting  from  some  definite 
point,  and  finally  the  atypical  course  of  the  disease,  protracted 
sometimes  in  wandering  erysipelas  for  weeks  and  even  months,  are 
points  of  difference  enumerated  by  Zuelzer,  of  Berlin,  the  author  of 
the  monograph  on  Erysipelas  in  von  Ziemssen's  "  Cyclopaedia  of  the 
Practice  of  Medicine."  To  these  should  be  added  the  striking  fact 
that  one  attack  of  erysipelas  so  far  from  protecting  an  individual 
from,  actually  predisposes  him  to,  another  attack. 

3.  Sex  does  not  seem  to  exercise  any  marked  influence  in  pre- 

fl  Clinique  Medicate  de  VHdtelDieu  de  Paris.     1865.     Tome  I.,  page  165. 
b  Art.  "  Erysipelas,"  in  von  Pitha  and  Billroth's  Handbuch  dtr  allgemeine  und 
specielle  Chirurgie. 

0  Archiv.  der  Heilkunde.     XL,  23. 

6  Handbuch  d.  histor.  und  geoyrapk.  Pathol.  I.,  page  243. 

£  Von  Ziemssen's  Cy'dopcedia  of  the  Practice  oj  Medicine.    Art.  "  Erysipelas." 


ERYSIPELAS,  2()~> 

disposing  to  this  disease.     Of  the  fatal  cases  in  England  between 
186:   and  1868,  56  percent,  occurred  in  males. 

4.  Erysipelas  is  a  disease  of  the  prime  of  life,  the  period  from 
the  20th  to  the  45th  year  being  specially  concerned  (Volkmann). 

5.  The  influence  of  climate  is  not  well  marked,  although  ery- 
sipelas is  mostly  a  disease  of  the  temperate  zone  of  both  hemi- 
spheres. 

6.  As  regards  season,  Hirsch  believes  that  erysipelas  is  particu- 
larly prevalent  in  damp,  changeable  weather,  with  unstable  tem- 
perature. Most  writers  are  of  opinion  that  the  disease  occurs 
more  frequently  in  the  colder  than  in  the  warmer  months  of  the 
year. 

Exciting  Causes. — These  are  briefly  two — (1.)  Contagion;  (2.) 
Inoculation. 

The  doctrine  of  the  contagiousness  of  Erysipelas,  first  promul- 
gated by  Wellsa  at  the  close  of  the  last  century,  has  been  adopted 
in  the  United  Kingdom  since  the  time  of  Graves.  In  France  it 
has  received  the  influential  support  of  Trousseau  and  other  physi- 
cians of  the  foremost  rank.  In  Germany  Zuelzer  and  Hirsch 
accept  it. 

Mr.  C.  de  Morgan,  in  Holmes'  "  System  of  Surgery,"  cites,  on  the 
authority  of  Dr.  Goodfellow,  a  most  extraordinary  instance  in 
which  erysipelas  spread  in  regular  order  through  award  of  thirteen 
beds  to  almost  every  patient  in  turn,  going  down  one  side  of  the 
ward  and  then  up  the  other  side.  In  the  "  Archiv.  fur  Heilkunde" 
for  1870  (Vol.  XI.,  23)  Dr.  B.  Konig,  of  Rostock,  records  the 
facts  relating  to  a  small  epidemic  in  the  hospital  of  that  town. 
The  outbreak  was  clearly  traced  to  infection  from  the  pillows  on 
the  operating  table,  which  had  become  deeply  discoloured  by  dried 
blood  from  other  patients.  From  the  day  when  these  pillows  were 
removed  no  fresh  cases  of  erysipelas  occurred.  The  pillows  were 
now  soaked  in  water,  and  a  brownish  solution  was  obtained  which 
was  inoculated  into  two  rabbits,  with  the  result  that  one  of  them 
had  an  affection  closely  resembling  erysipelas.     From  the  point  of 

'  a  Transactions  of  the  Society,  for  the  Improvement  of  Medical  and  Chtrurgical 
Knowkdye.     1800.     Vol.  II.,  page  213. 


206  ERYSIPELAS. 

inoculation,  a  diffuse  dermatitis  spread  over  the  belly,  produced 
(edema  of  the  prepuce,  bulla?  and  crusts  in  places,  and  disappeared 
after  twelve  days. 

Not  to  quote  authors  at  unnecessary  length  on  a  point  which 
may  be  regarded  as  settled,  I  will  merely  add  my  own  experience 
on  this  subject. 

In  November,  1874,  I  was  placed  by  Dr.  Stokes  and  Dr.  Alfred 
Hudson  in  charge  of  a  gentleman,  aged  thirty-seven,  who  was  the 
subject  of  progressive  locomotor  ataxy,  and  who  two  days  after 
exposure  to  cold  on  Friday,  the  20th,  displayed  constitutional 
symptoms,  which  proved  to  be  connected  with  an  erysipelas  of  the 
scrotum.  This  first  showed  itself  on  Wednesday,  the  25th,  and 
by  the  28th  it  had  become  gangrenous  and  involved  the  penis. 
On  the  30th  the  right  groin  was  implicated,  and  next  day  an 
erysipelatous  patch  appeared  on  the  back  of  the  right  hand. 
Towards  midnight  of  this  day,  December  1,  a  band  of  erysipelas 
spread  across  the  nose  and  downwards  into  the  month,  finally 
invading  the  tongue,  which  became  hugely  cedematous.  The  urine 
was  now  considerably  albuminous,  spec.  grav.  1018.  It  deposited 
amorphous  urates  and  a  few  fragments  of  granular  tube-casts. 
The  patient,  after  violent  delirium,  began  to  sink  rapidly,  and 
expired  at  4  a.m.  of  Thursday,  December  3. 

A  married  sister,  aged  thirty-six,  attended  the  patient  with 
singular  devotion  for  several  hours  before  his  death.  On  Tuesday, 
December  8,  she  complained  of  sore  throat  and  weakness.  Her 
pulse  was  extremely  rapid,  and  she  looked  seriously  ill.  Next  day 
the  throat  felt  and  appeared  to  be  better ;  but  the  mucous  mem- 
brane of  the  nose  looked  unhealthy,  and  the  orifice  of  the  nostrils 
was  swollen,  puffy,  and  sore.  On  the  following  day  the  nasal 
mischief  was  more  pronounced,  but  the  throat  continued  to 
improve.  On  Friday,  the  upper  lip  became  cedematous,  and  an 
attack  of  facial  erysipelas  was  clearly  in  progress.  On  Saturday, 
the  swelling  spread  upwards,  and  engaged  the  eyelids  and  forehead  ; 
across  the  latter  a  well-marked  line  of  demarcation  ran.  Temp,  in 
axilla  was  now  102-3°  ;  pulse,  128.  By  10  p.m.  the  inflammatory 
oedema  had  engaged  the  left  ear,  and  reached  the   hairy  scalp. 


ERYSIPELAS.  207 

T.  103-5°.  On  Thursday,  the  13th  (6th  day)  the  case  was  a 
typical  one  of  facial  erysipelas — P.  128;  T.  103'8°. 

This  lady's  illness  proved  exceptionally  severe,  and  for  many 
days  her  life  hung  in  the  balance.  The  temperature  rose  to  105*4° 
on  the  evening  of  the  tenth  day,  and  violent  delirium  was  followed 
by  symptoms  of  profound  nervous  prostration  and  by  paralysis  of 
the  bladder.  Ultimately  she  recovered  perfectly.  On  January 
11,  1875,  I  took  this  note:  "She  is  desquamating  everywhere,  as 
if  after  an  attack  of  scarlatina." 

It  should  be  mentioned  that  the  valet  of  the  unfortunate  gentle- 
man whose  illness  cost  him  his  own  life  and  placed  his  sister's  in 
such  jeopardy,  was  admitted  to  the  City  of  Dublin  Hospital  on 
December  11,  1874,  a  few  days  after  his  master's  death,  suffering 
from  abscess  in  the  right  tonsil  and  an  unhealthy-looking  herpetic 
eruption,  involving  the  right  side  of  the  neck  and  the  adjoining 
ear. 

On  February  21,  1884,  Jane  M.  was  admitted  into  Cork-street 
Fever  Hospital,  Dublin,  on  the  fourteenth  day  of  a  severe  attack  of 
facial  erysipelas.  She  died  next  day.  On  February  25th,  Ward- 
maid  Mary  Lennon,  who  attended  this  patient,  complained  of  not 
being  well.  On  the  28th  she  was  unable  to  leave  her  bed,  com- 
plaining of  severe  shivering,  headache,  and  pain  in  the  back.  It 
was  ascertained  she  was  suffering  from  facial  erysipelas.  Incuba- 
tion in  this  case  was  apparently  four  or  five  days. 

The  most  remarkable  series  of  cases  due  to  infection  which  have 
ever  come  under  my  notice,  occurred  in  the  year  1882.  They 
illustrate  especially  the  intimate  relation  which  exists  between 
erysipelas  of  the  throat  and  ordinary  cutaneous  erysipelas.  In  the 
month  of  February  in  the  year  named,  the  Secretary  of  the  Meath 
Hospital  occupied  as  his  sleeping  apartment  one  of  the  Collis 
Wards  ;  in  the  other,  separated  by  a  central  corridor,  lay  a  surgical 
patient  suffering  from  traumatic  erysipelas.  In  a  few  days  the 
Secretary  complained  of  painful  sore  throat,  which  was  accompanied 
by  severe  constitutional  disturbance,  high  fever,  and  extreme 
prostration.  After  a  short  time  the  larynx  became  engaged,  and 
symptoms  of   oedema  of  the  glottis  supervened.     The  treatment 


208  ERYSIPELAS. 

adopted  happily  proved  successful,  and  the  patient  gradually- 
recovered.  He  was  devotedly  attended  and  nursed  by  a  sister  who, 
in  a  few  days,  fell  ill  of  a  sharp  attack  of  facial  erysipelas,  which 
ran  a  normal  course.  And  now  comes  the  interesting  part  of  the 
story.  During  his  sister's  illness  the  Secretary  sent  bulletins  as  to 
her  state  to  a  married  sister  living  in  the  County  Sligo,  at  a  distance 
of  130  miles.  Letters  written  by  himself  were  despatched  on  the 
1 0th  and  13th  of  March,  and  a  post  card  followed  on  the  17th.  The 
lady  incautiously  placed  these  letters  and  post  card  under  her  pillow 
at  night,  with  the  result  that  on  the  21st  of  March  she  sicketied 
with  severe  sore-throat,  accompanied  by  intense  pain  and  much 
swelling.  She  was  attended  by  a  domestic  servant,  who  in  a  few 
days  developed  an  attack  of  facial  erysipelas. 

Hirsch  points  out  that  epidemics  complicated  with  throat- 
affection  have  been  repeatedly  described.  Of  one  such  outbreak 
at  Montrose  in  1822,  Gibsona  says  :  "  The  disease  was  not  so  much 
confined  to  the  head  or  face  as  common  erysipelas,  but  it  frequently 
attacked  other  parts  of  the  surface  of  the  body.  Sometimes  the 
internal  fauces  were  attacked,  ■  and  if  it  spread  to  the  trachea  it 
generally  proved  fatal." 

Trousseaub  narrates  a  strikingly  similar  instance  to  those  I  have 
just  detailed  of  the  spread  of  erysipelas  and  of  its  alternating  phases 
in  different  individuals.  I  give  his  very  words  : — "  J'etais  appele 
en  consultation  par  mon  honorable  ami  M.  le  docteur  Paris,  aupres 
d'un  M.  E.  .  .  .  chez  lequel  un  de  nos  chirui'giens  les  plus 
habiles,  °M.  le  Professor  Nelaton,  avait  e'te  oblige"  de  pratiquer  le' 
debridement  du  meat  urinaire  afin  de  faciliter  l'introduction  d'instru- 
ments  lithotripteurs.  M.  E.  .  .  .  succombait  a  un  erysipele 
gangreneux  du  prepuce,  qui  avait  eu  pour  point  de  depart  cette 
petite  incision.  La  veille  de  sa  mort,  sa  femme,  qui  l'avait  soigne 
avec  une  grande  sollicitude,  fut  prise  de  frissons ;  le  lendemain  elle 
avait  une  angine  violente,  et  vingt-quatre  heures  apres  un  drysipele 
de  la  face  d'une  extreme  gravite,  qui  l'emporta  alors  qu'  elle  semblait 
entrer  en  convalescence.     La  femme  de  chambre  tomba  malade  en 

a  Trans,  of  the  Edinburgh  Med.  Chir.  Soc,  1828.     Vol.  III.,  page  94. 
b  CUnique  Medicate  de  I'Mdtel  Dieu  de  Paris.     1865.     Vol.  I.s  page  171, 


ERYSIPELAS.  209 

meme  temps  que  sa  maitresse,  elle  n'avait  cegse"  de  donner  des  soins 
a  M.  E.  .  .  .  La  maladie  chez  elle  fut  caracterisee  surtout  par 
une  violente  angine,  et  par  un  erysipele  qui  se  limita  aux  paupieres." 

The  question  of  the  inoculability  of  erysipelas  has  been  definitely 
settled  by  experiments  on  animals  conducted  by  Orth,a  Koch,b 
Tillmanns,0  and  others,  and  most  decisively  of  all  by  Fehleisen's 
inoculation  experiments  on  man  with  micrococci  of  pure  cultivation.11 

Bacteriology. — According  to  Lukomsky,e  minute  cocci  occur  in 
chains  (Streptococci)  in  human  erysipelatous  skin,  and  in  the  fluid 
of  erysipelatous  bullae.  They  occupy  the  lymphatic  channels  of  the 
skin,  and  spread  along  them  as  the  disease  progresses.  These 
Streptococci  erysipelatis,  or  Micrococci  erysipelatosi,  as  Fehleisen 
called  them,  can  be  cultivated  artificially  in  nutrient  gelatine,  or 
agar-agar,  and  according  to  Orth  produce  typical  erysipelas  when 
re-inoculated  in  man  or  animals.  The  characteristic  erysipelatous 
blush  is  produced  by  inoculating  these  micro-organisms  in  the  ear 
of  a  rabbit-  In  the  human  subject  the  disease  was  produced  in 
fifteen  to  sixty  hours  after  inoculation/ 

Fehleisen8  made  a  number  of  inoculation  experiments  on 
human  subjects  with  the  therapeutical  intention  of  dispelling 
tumours.  All  the  experiments  succeeded,  and  the  erysipelas 
always  ran  a  perfectly  normal  course.  A  beneficial  result  was 
obtained  in  cases  of  lupus,  cancer,  and  sarcoma.  Hence  this 
induced  disease  has  received  the  name  "Erysipele  salutaire." 

The  pathogenic  micro-organism  of  erysipelas  spreads,  as  has 
been  stated,  by  the  lymphatics,  which  may  be  seen  infiltrated  with 
aggregated  masses  of  spherules  ;  thence  it  penetrates  into  the  tissues 
and  forms  chains  or  swarms  of  spherical  cocci,  'Sfju  in  diameter.  It 
excites  a  specific  inflammation  and  leads  to  tissue  necrosis.  Cul- 
tivated on  gelatine,  it  forms  whitish  colours  but  does  not  liquefy  it. 

*  Arch,  fur  experiment.  Pathologic     1873.     I.,  81. 

b  Untersuch.  iiber  die  Aetiologie  der  Wundinfections-Krankheiten.     1878. 
c  Billroth  and  Lucke's  Deutsche  Chirurgie.     V.,  75. 

*  Deutsche  Zeitschrift  fur  Chirurgie.     1882.     XVI.,  391. 
e  Virchow's  Archiv.     1874.     LX,  418. 

f  E.  M.  Crookshank.   Manual  of  Bacteriology.  Second  Edition.    1889.    P.  200. 

*  Deutsche  Zeitschrift  fur  Chirurgie,  1882,  XVI.,  391  ;  and  Sitzungsber.  der 
Wiirzb.  phys.-med.  Qesellschaft,  1882.     No.  8. 

P 


210 


CHAPTER  XXIL 

Erysipelas  {continued). 

Clinical  History — Temperature — Diagnosis — Prognosis 
and  Mortality. 

Clinical  History. — Vabieties  of  Erysipelas  according  to  depth  of  surface 
affected  :  (1.)  Simple  or  cutaneous  ;  (2.)  Phlegmonous,  or  cellulo-cutaneous  ; 
(8.)  Diffuse  cellulitis. — Stages  of  incubation,  invasion,  eruption,  defervescence. 
Erysipelas  faucium,  pulmonum. — Temperature. — Diagnosis. — Prognosis  and 
Mortality. 

Clinical  History. — Bearing  in  mind  the  poly  typical  nature  of 
erysipelas,  we  are  not  surprised  to  find  that  its  course  is  less 
cyclical  than  that  of  the  other  eruptive  fevers.  In  fact  no  two 
cases  correspond  exactly  in  mode  of  origin,  symptoms,  and  dura- 
tion. All  stages  of  the  exanthem  may  be  observed  simultaneously 
in  the  same  individual — its  beginning,  acme,  decline,  and  resulting 
desquamation.  Notwithstanding  this,  it  will  be  convenient  to  con- 
sider the  disease  in  the  same  systematic  way  as  the  others  of  its 
class,  premising  that  it  is  classified  as  regards  the  degree  or  depth 
of  surface  to  which  the  inflammation  penetrates  as — 

1.  Simple,  or  cutaneous,  Erysipelas. 

2.  Phlegmonous,  or  cellulo-cutaneous,  Erysipelas. 

3.  Diffuse  inflammation  of  the  subcutaneous  areolar  or  cellular 

tissue,  or  Diffuse  Cellulitis. 

This  is  a  commonly  adopted  but  quite  artificial  classification. 

1.  Stage  of  Incubation. — This  period  is  of  rather  indefinite 
duration.  On  an  average  it  lasts  about  seven  days,  being  sometimes 
shorter,  sometimes  longer — for  example,  Dr.  Roberts  assigns  to  it 
a  duration  of  from  10  to  14  days.  In  the  cases  from  my  own 
practice,  which  I  have  detailed,  the  incubative  period  varied  in 
length  from  4  or  5  to  8  or  perhaps  10  days,  and  these  limits  are 
probably  the  most  common. 


ERYSIPELAS.  211 

IT.  Stage  of  Invasion, — Taking  its  origin  in  a  herpetic  ulcera- 
tion, or  other  more  or  less  trivial  lesion  of  the  pharynx,  mouth,  lips, 
nose,  ears,  or  eyes,  facial  erysipelas  causes  general  discomfort,  loss  of 
appetite  (anorexia),  vomiting,  and  diarrhoea.  It  is  usually  ushered 
in  hy  chills,  rigors,  or  even  epileptoid  convulsions,  as  pointed  out  by  Dr. 
Hathurst  Woodman.  The  temperature  rises  rapidly  in  a  few  hours, 
often  to  104°  F.  (40°  C),  or  even  higher.  Severe  pain  in  the  throat  is 
commonly  felt,  especially  in  cases  due  to  contagion.  There  is  a  vivid 
redness  over  the  uvula,  velum  pa/ati,  and  tonsils,  and  the  glands  in  the 
neck,  and  under  the  lower  jaw,  are  nearly  always  swelled  and  tender 
on  pressure. 

In  an  account  of  an  outbreak  observed  in  the  Paris  hospitals, 
Cornil  describes  a  purple-red,  shining,  oedematous  swelling  of  the 
whole  pharyngeal  mucous  membrane,  which  appears  as  if  varnished. 
The  tonsils  may  remain  free  from  these  changes.  Great  pain  is 
felt  in  swallowing  (dysphagia),  and  there  may  be  salivation.  I 
would  like  to  lay  special  stress  on  the  painful  nature  of  erysipelatous 
angina.  It  is  a  symptom  the  presence  of  which  I  have  repeatedly 
verified  by  personal  observation.  To  this  variety  of  erysipelas  the 
name  Erysipelas  Faucium  is  applied. 

III.  Stage  of  Eruption. — After  a  few  hours,  or  one,  two,  or 
three  days,  the  erysipelatous  inflammation  spreads  from  the  pharynx 
or  its  other  point  of  origin  on  to  the  face,  every  part  of  which  may 
be  invaded  except  the  chin,  for  an  anatomical — or  rather  histo- 
logical— reason,  which  will  be  explained  under  the  heading  "  Patho- 
logy." The  dermatitis  tends  to  advance  in  an  ever-enlarging  circle 
from  the  original  focus,  while  a  well-defined  and  raised  margin 
marks  the  approach  to  a  given  spot  of  the  accompanying  swelling 
and  redness.  The  natural  lines  of  cleavage  of  the  skin  modify 
the  rate  and  manner  of  extension  of  the  inflammation.  Where  the 
skin  is  tightly  stretched  (as  on  the  scalp)  or  firmly  bound  down  (as 
on  the  chin),  it  progresses  slowly  and  irregularly,  or  in  a  zigzag 
fashion,  along  the  lines  of  least  resistance.  On  the  other  hand, 
regions  where  the  subcutaneous  areolar  tissue  is  lax  (such  as  the 
eyelids  and  scrotum)  become  rapidly  and  enormously  swollen  (J.  J. 
Pringle).     The  patient  now  complains  of  stiffness  and  a,  burning, 


212  ERYSIPELAS. 

tingling  sensation  in  the  affected  area  of  the  skin,  the  surface  of 
which  is  swollen,  red,  hard,  and  tense  from  effusion  of  a  serous 
fluid,  rich  in  young  cells,  into  the  subcutaneous  areolar  tissue. 

The  most  striking  woixUpicture  of  erysipelas  with  which  I  have 
ever  met  is  Sir  Thomas  Watson's  description.  He  says  : — "  The 
lips  swell  enormously,  the  cheeks  enlarge,  the  eyes  are  sealed  up 
by  their  (edematous  and  prominent  lids,  and  all  traces  of  the  natural 
countenance  are  effaced.  I  know  of  no  disease  except,  perhaps, 
the  confluent  smallpox,  which  so  completely  and  speedily  deforms 
and  disguises  the  visage  of  the  patient.  A  stranger  seeing  a  young 
female  in  the  height  of  the  disorder,  and  revisiting  her  after  her 
recovery,  is  astonished  at  the  change.  It  seems  as  if,  by  some 
magic  process,  such  as  Ave  read  of  in  our  nursery  tales,  a  hideous 
monster  has  been  metamorphosed  into  a  comely  damsel."  a 

It  has  been  already  stated  that  the  swelling  and  redness  gene- 
rally stop  at  the  edge  of  the  hairy  scalp.  This  was  stated  by 
Watson  to  be  particularly  the  case  if  the  dermatitis  spread  sym- 
metrically across  the  face  from  the  nose;  but  the  accuracy  of  the 
observation  is  with  reason  called  in  question  by  Trousseau.b  Some- 
times— and  in  this  respect  it  exactly  resembles  a  scald — the 
inflamed  surface  becomes  covered  with  irregular  blebs  or  blisters 
(bullae),  particularly  on  very  vascular  surfaces  like  the  cheeks. 
Vesication,  however,  is  often  wanting,  so  there  is  nothing  dia- 
gnostic in  this  phenomenon.  The  vesicles,  or  blebs,  dry  up  into 
crusts,  as  a  rule  ;  but  where  the  dermatitis  dips  deeply,  or  the 
tension  from  oedema  is  extreme,  as  in  the  eyelids,  suppuration  is 
apt  to  take  place,  and  the  tissues  may  even  slough. 

As  regards  a  given  portion  of  surface,  when  the  redness  has 
lasted  three  or  four  days,  it  fades,  swelling  quickly  subsides,  and 
desquamation  sets  in.  Nothing  is  more  curious  than  to  see  these 
changes  taking  place  while  the  advancing  disease  is  attacking 
other  parts  for  the  first  time.  During  all  this  time  the  fever  ebbs 
and  flows  according  to  the  progress  of  the  malady. 

*  Lectures  on  the  Principles  and  Practice  of  Physic.  Third  Edition.  London  : 
John  W.  Parker.     1848.     Vol.  II.,  page  827. 

6  Clinique  Medicale  de  VHdtel  Dieu  de  Paris.    1865.    Tome  I.,  page  171. 


ERYSIPELAS.  213 

IV.  Stage  of  Defervescence. — When  the  swelling  and  redness 
cease  to  spread,  the  temperature  falls  rapidly  in  uncomplicated 
cases.  In  other  instances  defervescence  is  a  very  tedious  process 
indeed,  occurring  by  lysis  rather  than  by  crisis.  Or  the  tempera- 
ture range  may  closely  simulate  that  of  pyaemia.  This  happens 
when  the  dermatitis  wanders  all  over  the  body,  or  jumps  (as  it  did 
in  one  of  the  cases  detailed  by  me  above)  from  one  part  of  the 
body  to  another.  This  form  of  the  disease  receives  the  name  of 
erratic  or  vagrant  erysipelas  (erysipelas  migrans) — the  "  erysipele 
ambulant "  of  French  writers.  In  such  cases  the  illness  may  be 
protracted  for  one  or  two  months,  and  not  only  every  part  of  the 
surface  of  the  body,  but  the  whole  tract  of  mucous  membranes,  and 
even  the  lungs,  and,  I  believe,  the  pleurae,  may  in  turn  become 
affected.  Dr.  Peter,11  of  Paris,  has  drawn  attention  to  the  spread  of  the 
inflammation  from  the  pharynx  to  the  respiratory  passages,  causing 
bronchitis,  bronchiolitis  (capillary  bronchitis),  and  pneumonia. 

In  a  case  observed  by  me  at  Cork-street  Fever  Hospital  many 
years  ago,  the  reverse  of  this  happened.  A  man  was  admitted 
suffering  from  Pneumonia  migrans.  After  some  days,  a  blush  of 
erysipelas  showed  over  one  shoulder,  and  spread  thence  down  the 
back,  and  simultaneously  the  pneumonic  symptoms  subsided.  So 
great  was  the  impression  made  upon  me  by  this  case  that  ever  since 
I  have  recognised  the  propriety  of  considering  erysipelas  pulmonum 
as  a  distinct  species  of  the  great  genus  Pneumonia. 

Temperature. — But  little  remains  to  be  added  to  the  incidental 
remarks  on  the  behaviour  of  the  temperature  which  have  been 
made  in  the  foregoing  account.  "  Facial  Erysipelas,"  writes  Wun- 
derlich,b  "  is  pre-eminently  a  polytypical  disease,  and  in  many  cases 
it  is  quite  atypical."  He  adds :  "  At  present  it  is  not  possible  to 
associate  special  forms  of  erysipelas,  or  special  causes  of  it,  with 
particular  forms  of  fever  curves." 

The  temperature  commonly  rises  in  a  few  hours  to  nearly  40°  C. 
(104°  F.)  or  even  higher.     So  long  as  the  cutaneous  or  anginal 

a  Dictionnaire  Encyclopedvque  des  Sciences  Medicates.  Tome  IV  ,  page  720. 
Art.  "  Angines."  .       <mi    . 

b  Medical  Thermometry.     New  Syd.  Soc.     1871.     Page  351. 


214  ERYSIPELAS. 

inflammation  develops  and  extends,  so  long  does  the  temperature 
tend  upwards  to  104°,  105*8°,  or  even  106-7°  in  the  evenings,  falling 
to  102°,  103°,  or  only  104°  in  the  mornings.  Sometimes  there  are 
intermissions  of  pyrexia  at  times,  with  great  exacerbations  at  other 
times.  When  defervescence  does  set  in,  it  generally  goes  on  with 
such  speed  that  in  the  course  of  a  single  night,  the  thermometer 
falls  to  normal  or  nearly  so.  In  some  instances,  after  several  days 
a  fresh  and  striking  rise  of  temperature  occurs,  which  either  accom- 
panies or  heralds  a  new  extension  of  inflammation. 

In  fatal  cases  death  usually  occurs  with  very  high  temperatures. a 
Complications  and  Sequelae. — For  the  most  part,  the  complica- 
tions of  erysipelas  are  one  or  other  of  the  ordinary  symptoms 
presented  in  an  aggravated  form.  Thus  diarrhoea,  nausea  and 
vomiting,  oedema  of  the  fauces,  glossitis,  sloughing  and  abscess  of 
the  eyelids,  may  one  and  all  interfere  with  the  normal  course  of 
the  malady  and  endanger  the  patient's  life  by  prolonging  his  illness 
and  shattering  his  strength. 

Apart  from  the  foregoing,  the  complications  are : — 

1.  Cerebral  symptoms,  namely,  headache,  delirium,  insomnia, 
tremors,  mania,  and  coma,  ending  in  death.  This  formidable  group 
is  usually  dependent  on  hyperpyrexia  and  not  on  meningitis,  which 
is  extremely  rare  in  erysipelas. 

2.  Bronchitis  and  Pneumonia — the  latter  either  of  the  nature  of 
a  lobular  pneumonia  in  bronchiolitis,  or  of  severe  croupous  pneu- 
monia (Trousseau,  Ritzmann.) 

3.  Hypostatic  Congestion  of  the  Lungs,  especially  in  protracted 
cases  (Yolkmann.) 

4.  Pleuritis,  considered  by  Lawrence,  Wutzer,  and  Volkmann, 
to  be  a  direct  extension  of  erysipelas  to  the  serous  membrane— by 
contiguity,  not  continuity. 

5.  The  "  Puerperal  State  "  either  in  lying-in  women  or  in  newly 
born  infants.  In  the  latter  case  the  disease  is  called  in  France 
"  Erysipele  des  Nouveau-nes."     It  usually  begins  in  infants  a  few 

a  Wunderlich,  loc.  cit.,  page  354  ;  Blass :  Beobachtungen  der  Erysipelas, 
Leipzig,  1863 ;  Eulenburg,  Ventralblait,  1866,  page  65 ;  Ponfick,  Deutsche 
Klinik,  1867,  20-26. 


5IPELAS. 

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ERYSIPELAS.  215 

hours  or  days  after  birth  as  a  red  blush  over  the  hypogastrium 
rather  than  about  the  umbilicus.  It  commonly  ends  in  peritonitis 
and  is  invariably  fatal  in  such  young  children,  the  explanation 
according  to  Trousseau  and  Paul  Loraina  being  that  the  same 
"  epidemic  puerperal  influence "  affects  both  recently  delivered 
women  and  new-born  infants. 

6.  Peritonitis,  regarded  by  Dr.  Samuel  Wilksb  as,  in  some 
cases  at  all  events,  the  result  of  a  direct  extension  of  erysipelas 
from  the  abdominal  walls. 

7.  Leukocytosis. — In  his  "  Cellular  Pathology,"  Vircbowc  pointed 
out  that  the  acute  irritation  of  the  glandular  apparatus  led  to  this 
condition,  which  becomes  serious  in  "  wandering  erysipelas  "  when 
this  form  of  the  disease  attacks  debilitated  persons. 

8.  Pyaemia  is  a  rare  sequela.  In  erysipelas  associated  with 
severe  or  extensive  injuries,  Zuelzer  and  Volkmann  both  consider 
that  pyaemia  may  actually  be  of  use,  by  favouring  the  destruction 
and  consequent  dispersion  of  any  embolic  infarctions  and  thrombi 
which  may  have  formed. 

9.  Extensive  gangrene  of  the  skin  often  points  to  severe  pyasmic 
and  septicaemic  phenomena  generally  of  evil  omen,  as  in  one  of  the 
cases  detailed  by  me  in  the  foregoing  pages.  A  marked  bloody  hue 
of  the  contents  of  the  blebs  is  often  the  first  sign  of  commencing  gan- 
grene, which  may  at  times  be  checked  by  early  puncturing  (Zuelzer). 

Pathology. — There  is  little  that  is  specific  in  the  morbid 
anatomy  of  erysipelas.  According  to  Ponfick,  heart,  spleen,  and 
kidneys  are  the  seat  of  a  more  or  less  parenchymatous  degenera- 
tion ;  but  this  change  was  shown  by  Liebermeister  to  be  common 
to  all  severe  febrile  affections.  The  morbid  histology  of  erysi- 
pelas has  been  studied  with  care  by  Biesiadecki,d  Volkmann,  and 
Steudener.  The  first-named  observer  showed  that,  in  the  facial 
form  of  the  disease,  simple  erysipelas,  like  phlegmonous  inflamma- 
tion, affects  the  skin  in  its  whole  thickness  and  the  subcutaneous 

*  La  Fiivre  puerperale.     Paris.     1855. 
b  Guy's  Hospital  Reports,  1861. 
c  Cellular  Pathologie.     1871.     Page  230. 

d  Sitzungsbericht  d.  k  Acad,  der  Wissenschoft  zu  Wien.  1867.  Vol.  IT., 
p.  231. 


216  ERYSIPELAS. 

areolar  tissue.  In  the  same  way,  Volkmann  found  the  deeper 
strata  of  the  cutis,  as  well  as  the  subcutaneous  tissue  infiltrated 
with  enormous  numbers  of  granular  leucocytes.  In  1869,  Dr. 
Charlton  Bastian,a  finding  the  small  arteries  and  capillaries  of  the 
brain  plugged  with  embolic  masses  of  white  blood-corpuscles  in  a 
man  who  died  from  erysipelas  in  a  state  of  delirium  and  stupor, 
suggested  that  this  pathological  condition  was  the  cause  of  the 
cerebral  symptoms  named. 

The  globular  bacteria  of  erysipelas  (Punctiform  Bacteria  of 
Ehrenberg,  Microspheres  of  Cohn),  were  first  discovered  by  Huter. 
They  were  everywhere  forthcoming  in  the  inflamed  tissues,  being 
especially  abundant  in  the  oedematous  parts,  much  less  so  in  the 
blood.  In  1883,  Fehleisen b  described  the  micro-organism  of  the 
disease  more  particularly  as  a  coccus  arranged  in  chains ;  to  it  he, 
therefore,  gave  the  name  of  Streptococcus  erysipelatis.  More 
recently,  V.  Noorden c  found  streptococci  in  blood  taken  from  the 
body  of  a  woman  who  had  died  of  erysipelas. 

Richter,  of  Gbttingen,1*  in  1744,  first  put  forward  the  view  that 
erysipelas  was  an  inflammation  of  the  lymph  vessels.  According 
to  Trousseau,  erysipelas  is  essentially  a  capillary  lymphangeiitis, 
or  inflammation  of  the  minute  lymphatic  vessels  of  the  skin.  All 
this  may  be  true,  but  it  does  not  shake  our  faith  in  the  infective, 
specific,  and  febrile  nature  of  the  disease,  and  therefore,  v,ith  all 
its  differences  from  the  other  eruptive  fevers,  we  still  include  ery- 
sipelas with  them  as  a  true  exanthem. 

In  a  very  suggestive  paper,  entitled  "  Recent  Advances  in  the 
-ZEtiology  of  Diseases  of  the  Skin  and  their  bearing  upon  Treat- 
ment," read  on  November  20,  1891,  before  the  Royal  Academy  of 
Medicine  in  Ireland,  Dr.  Walter  G.  Smith  observed  that  "  erysipelas 
and  lymphangitis  are  not  convertible  terms."  He  goes  on  to  say : 
"  It  is  generally  held  as  settled  that  acute  suppuration  is — as  Ogston 
first  showed — due  to  the  action  of  micro-organisms;  but  it  is  a 

■  Trans.  Path.  Soc.  of  London.     1869.     Page  8. 

b  Die  Aetiologie des  Erysipels.     Berlin.     1883. 

«  Munch,  rned.   Wochensrhrift.     Vol.  XXXIV.     No.  3.     1887. 

d  l)e  Erysipelate  Dissertatio.     Opuscula  Medica.     Gottingen.     1744.     I. 


ERYSIPELAS.  217 

difficult  matter  to  determine  whether  erysipelas  is  an  entity,  a 
truly  specific  disease,  or  whether  it  does  not  represent  a  phase  or 
mode  of  action  of  the  pus-producing  organisms.  Watson  Cheyne 
is  inclined  to  uphold  the  specific  character  of  the  erysipelas  germ, 
while  Levy  in  a  valuable  paper  (Archiv.  fur  experiment.  Path, 
und  Pharm.,  xxix.,  '  Ueber  die  Mikro-organismen  der  Eiterung,' 
page  135)  teaches  that  Streptococcus  pyogenes  is  at  once  an  exciter 
of  suppurative  processes  and  of  erysipelas. 

"  It  is  more  than  probable  that  there  are  several  species  of 
erysipelas  due  to  different  bacteria." 

Pfleger  considers  that  the  mode  of  advance  of  the  dermatitis 
depends  not  so  much  on  the  course  of  the  lymph  channels,  as 
originally  held  by  Billroth,  but  mainly  upon  the  arrangement  of 
the  subcutaneous  connective  tissue  bundles.  They  everywhere 
interlace  so  as  to  form  rhomboidal  meshes ;  but  these  are  usually 
horizontal  or  oblique,  except  upon  the  chin,  where  their  direction 
is  vertical.  Hence,  the  chin  always  remains  untouched  by  erysi- 
pelas, as  pointed  out  by  Volkmann.  Pfleger  also  maintains  that 
wherever  the  skin  is  tied  down  to  the  deeper  parts  the  spread  of 
the  disease  is  retarded  or  arrested,  as,  for  example,  along  the  crest 
of  the  ilium,  and  Poupart's  ligament.  Billroth a  uses  a  striking 
illustration  when  he  says  that  the  redness  advances  through  the 
skin  in  many  cases,  just  as  fluids  spread  in  blotting-paper,  rounded 
tongue-like  subcutaneous  projections  shooting  out,  which  are  fol- 
lowed by  a  broader  advance. 

The  formation  of  vesicles  or  blebs  has  no  specific  significance. 

Metschnikoff  has  described  cells  which  he  calls  "microphages"b 
and  "macrophages"0  in  connection  with  the  erysipelatous  process. 
The  microphages  are  small  free  leucocytes  which  he  discovered  in 
the  margin  of  an  erysipelatous  patch  of  skin,  and  which  he  believed 
possess  the  power  of  destroying  the  infecting  micrococci  of  the 
disease.     The   macrophages    are    large   leucocytes    also   found  in 

a  Lectures  on  Surgical  Path,  and  Therapeutics.  New  Syd.  Soc.  London. 
1888..    Vol.  II.,  page  10. 

b  Gk.  fiiKp6s,  small,  <pay4u>,  1  devour. 
c  Gk.  ixaKj>6s,  great,  (puyiw,  I  devour. 


218  ERYSIPELAS. 

structures  affected  with  erysipelas.  Metschnikoff  says  that  they 
consume  and  destroy  the  debris  of  the  dead  and  dying  microphages.a 

According  to  Volkmann  and  Steudener,  as  the  inflammation 
wanes,  the  leucocytes  disappear  in  the  subcutaneous  tissue  with 
extraordinary  rapidity,  breaking  down  in  a  few  hours  into  a 
granular  debris.  In  the  superficial  layers  of  the  cutis  they  remain 
visible  a  little  longer ;  but  within  a  day  or  two  all  signs  of  tissue 
changes  may  have  vanished.  Meanwhile,  the  vesicles  or  bullae 
have  dried  up  into  yellowish  crusts.  The  cuticle  is  subsequently 
shed  either  in  flakes  or  as  a  branny  powder  (Hilton  Fagge), 

When  the  scalp  is  attacked,  the  hair  usually  falls  off  during  con- 
valescence. Haight  says  that  this  happens  because  the  external 
root-sheath  is  separated  from  the  vitreous  layer  of  the  follicle  as 
far  as  its  junction  with  the  papilla  by  the  serous  infiltration.  The 
hairs  quickly  form  again. 

Diagnosis. — The  recognition  of  erysipelas  is  generally  easy  once 
the  eruption  has  shown  itself  upon  the  skin.  Frank  has  pointed 
out  that  when  a  patient  has  had  febrile  symptoms  for  some  hours 
accompanied  with  pain,  tenderness,  and  swelling  of  the  lymphatic 
glands,  erysipelas  is  doubtless  coming  on.  Chomel  held  the  same 
view,  and  Campbell  de  Morgan  relates  that  "  Busk  is  so  convinced 
of  the  invariable  occurrence  of  affection  of  the  glands  before 
erysipelas  appears,  as  to  consider  it  a  pathognomonic  symptom. "b 

In  this  view  Trousseau0  also  concurs,  and  he  quotes  the  following 
passage  from  Borsieri,  who  noted  swelling  of  the  lymphatic  glands 
as  marking  the  onset  of  the  malady : — "  Illud  etiam  memoria,  probe 
tenendum  est,  quod  crebris  ex  observationibus  constitit,  si  erysipelas 
artubus  inferioribus  incubiturum  sit,  inguinis  et  femoris  glandulas 
conglobatas,  vasis  cruralibus  additis,  antequam  se  exserat,  leviter 
dolere  atque  intumescere  consuevisse,  axillares  vero  ac  cervicales, 
si  brachiis  aut  superioribus  locis  immineat." 

The  anginal  form  is  often  not  easily  recognised.     The  pain- 

a  See  the  New  Syd.  Society's  Lexicon  of  Medicine,  sub  vocibus  "  Macrophage" 
and  "Macrophage." 

b  Thomas  Bryant.  Manual  for  the  Practice  of  Surgery.  London  :  1884. 
Fourth  Edition.     Vol.  I.,  page  100. 

0  Clinique  Medicale  de  I'Hdtel  Dieu.     1865.     Tome  I.,  page  169. 


ERYSIPELAS.  219 

fnlness,  oedema,  and  implication  of  the  cervical  glands  are  impor- 
tant elements  of  diagnosis. 

Erysipelas  has  to  he  distinguished  from — 

1.  Simple  erythema  (E.  simplex),  which  is  a  transitory 
hyperaemia  of  the  skin,  running  its  course  with  little,  if  any, 
pyrexia,  without  pain,  swelling,  or  desquamation.  In  it  the  glands 
also  are  not  involved. 

2.  Urticaria,  or  nettle-rash,  which  is  intensely  itchy  and  con- 
sists of  wheals  distributed  here  and  there  over  the  body. 

3.  Simple  lymphangeiitis,  which  shows  a  streaked  or  spotted, 
seldom  a  confluent,  redness,  extending  centripetally,  the  inflamed 
lymphatics  appearing  like  firm  cords.  It  often  terminates  in  sup- 
puration. 

4.  Diffuse  phlegmonous  inflammation,  which  shows  a  darker 
redness,  nowhere  sharply  defined,  and  a  board-like  hardness.  It 
generally  ends  in  suppuration. 

5.  Pemphigus. — This  is  distinguished  by  its  relative  chronicity, 
its  localisation,  the  absence  of  oedema,  and  the  inconstant  implica- 
tion of  the  lymphatic  vessels  and  glands. 

6.  Eczema  rubrum,  in  which  the  dermatitis  is  severe,  painful, 
and  oedematous.  The  pyrexia,  however,  and  constitutional  disturb- 
ances are  ill-defined,  and  the  disease  is  comparatively  limited.  A 
coloured  drawing  of  acute  eczema  will  be  found  in  the  New  Syden- 
ham Society's  "  Atlas  of  Skin  Diseases  "  (Plate  X VI.). 

7.  Hilton  Fagge  has  known  blunders  repeatedlv  committed  in 
the  differential  diagnosis  of  herpes  zoster  of  the  forehead  and  face, 
and  erysipelas. 

Herpes  does  not  cross  the  middle  line ;  there  is  no  desquamation, 
and  the  vesicles  in  time  dry  up  into  characteristic  dark  brown 
eschars,  embedded  in  the  skin.  I  would  add  that  the  febrile  move- 
ment in  herpes  zoster  is  not  acute  as  a  rule. 

Prognosis. — This,  so  far  as  facial  erysipelas  is  concerned,  is 
generally  favourable.  One  of  the  Aphorisms  of  Hippocrates  on 
Erysipelas  is  well  worth  quoting.  It  runs  thus  :  "  'Epva-iireKas 
e^codev  Kara^eofievov  eicro)    rpiireadai  ov/c   dyaOov,   eacodev 


220  ERYSIPELAS. 

Be  e£a>  ayadov* — "  For  superficial  erysipelas  to  turn  inwards  is 
not  a  good  sign ;  for  internal  erysipelas  to  become  superficial  is  a 
good  sign." 

Billroth  says  the  disease  commonly  lasts  from  2  to  10  days:  14 
days  is  an  unusual  duration.  The  longest  case  that  he  ever  saw  lasted 
32  days  and  terminated  fatally.  Zuelzer  assigns  a  much  longer  dura- 
tion than  this,  and  one  of  my  own  cases  ran  to  66  days.  The  average 
duration  is — 12  days  (Velpeau)  ;  13|  days  (Heyfelder)  ;  10,  12,  or 
14  days  (Zuelzer).     Relapses  and  recrudescences  are  common. 

The  mortality  varies  much  according  to  circumstances — Wun- 
derlich  had  only  3  per  cent,  of  deaths,  Volkmann  5  per  cent. ;  in 
the  American  War  (1862)  the  mortality  among  surgical  cases  was 
11  per  cent.  Of  137  cases  without  complications  which  Billroth 
had  under  his  care  at  Zurich,  10  died. 

Puerperal  women,  new-born  children,  old  people,  the  subjects  of 
debilitating  chronic  diseases,  sufferers  from  any  of  the  other  erup- 
tive or  continued  fevers,  the  victims  of  intemperance,  all  run  a  bad 
chance  if  attacked  by  erysipelas. 

Erysipelas  migrans  is  particularly  dangerous,  but  ordinary  ery- 
sipelas may  kill,  according  to  Trousseau,  by  coma,  consequent  on 
effusion  within  the  head ;  by  asphyxia,  owing  to  oedema  of  the 
glottis ;  or  by  asthenia.  This  last  cause  of  death  operates  espe- 
cially in  the  wandering  or  erratic  variety. 

Although  erysipelas  most  frequently  ends  in  recovery,  the  pro- 
gnosis should  be  guarded  in  all  cases.  Bad  signs  are :  evidences  of 
blood-poisoning,  severe  head-symptoms,  typhoid  or  ataxic  symptoms, 
extension  of  the  inflammation  to  the  larynx  or  bronchial  tubes,  a 
dark  coloured  rash  with  livid  vesicles  or  bullae,  and—  as  pointed  out 
by  Dr.  F.  Roberts — a  sudden  disappearance  of  the  external  inflam- 
mation with  a  coincident  development  of  internal  symptoms. 

a  Hippocratis  Coi  Aphorism.  Lib.  vi.  Sec.  7.  Aphor  25.  Editio  Foesii. 
Francofurti.     1624. 


221 


CHAPTER  XXIIL 

Treatment  of  Erysipelas. 

Expectant  Treatment. — Constitutional  (or  general)  and  Topical  Treat- 
ment.— Constitutional  Treatment  :  tincture  of  the  perrhloride  of  iron, 
quinine,  ammonia  and  bark  in  effervescence,  salicylate  of  sodium  (Hallopeau), 
cold  baths,  alcoholic  stimulants,  effervescing  draughts  in  gastro-intestinal  dis- 
turbance, opium  or  morphin  in  threatening  delirium. — Topical,  or  Local 
Treatment:  indications— (1.)  to  relieve  pain  and  tension;  (2.)  to  check  the 
spread  of  inflammation  ;  (3.)  to  destroy  the  infectious  matter  in  situ. — Leeches 
are  contra-indicated. — "Ectrotic"  method.— Topical  use  of  nitrate  of  silver. — 
Rectified  oil  of  turpentine. — Sulpho-carbolate  of  sodium. — Sprays. — Special 
treatment  of  oedema  of  the  eyelids,  sore  throat,  laryngitis,  and  cedema  of  the 
glottis,  tension  of  the  skin,  gangrene. 

Many  patients  suffering  from  uncomplicated  facial  erysipelas 
quickly  recover,  with  very  simple  management  indeed.  The  expec- 
tant treatment  is  the  rational  treatment  in  such  cases.  Trousseau 
having  alluded  to  the  active  measures  adopted  in  some  hospitals 
against  the  disease,  somewhat  satirically  says :  "  Vous  avez  vu, 
malgre  cela,  la  maladie  guerir,"  and  adds  :  "  I'erysipele  est  done  une 
de  ces  affections  qui  guerissent  d'elles-memes,  je  parle  de  I'erysipele 
qui  surprend  l'individu  en  bonne  sante,  et  non  plus  de  celui  qui 
survient  dans  le  cours  d'autres  maladies."a 

This  is  all  quite  true,  but  we  are  often  called  upon  and  bound  to 
adopt  other  means  than  those  which  the  great  French  physician 
embraces  under  the  term  "  expectant  treatment,"  namely,  to  keep 
the  patient  in  bed  protected  from  draughts,  to  prescribe  slightly 
acidulated  diet  drinks,  to  give  laxatives  as  required,  to  relieve 
vomiting  by  purgatives,  and  to  give  nourishment  freely — his  very 
words  are  dramatic:  "J'alimente,  j'alimente  alors  meme  qu'il  y  a 
de  la  fievre,  alors  meme  qu'il  y  a  du  delire  .  .  .  au  lieu  de 
les  tenir  a  une  diete  rigoureuse,  je  reste  spectateur  de  la  lutte  de 
laquelle,  je  le  sais,  la  nature  sortira  victorieuse,  si  je  ne  la  trouble 
pas  dans  ses  operations  ;    je  me  tiens  les  bras  crois^s :  et,  je  le 

a  Clinique  Medicate  de  I'tidtel  Dieu  de  Paris.  Tome  I.,  page  174.  Paris  : 
1865, 


222  ERYSIPELAS. 

repete,  parmi  le  grand  nombre  d'erysipeles  que  j'ai  vus,  trois  tout 
au  plus  ont  eu  une  terminaison  fatale ;  dans  tous  les  autres  cas  la 
maladie  s'est  dteinte  d'elle-meme." 

The  treatment  of  erysipelas  naturally  falls  under  two  headings — 
constitutional— or  general — and  topical,  and  yet  it  is  hard  to 
dissever  one  from  the  other,  for  to  destroy  the  infectious  matter  is 
one  of  the  objects  alike  of  constitutional  and  of  topical  treatment. 

Constitutional  Treatment. — Apart  from  the  management  of  the 
surroundings,  dieting,  and  nursing  of  an  erysipelatous  patient,  the 
following  remedies  have  enjoyed  a  well-merited  reputation  while 
not  attaining  to  the  rank  of  a  specific  against  the  disease : — 

1.  Tincture  of  the  perchloride  of  iron,  recommended  by  Hamil- 
ton Bell  in  1851,  has  since  then  been  given,  especially  in  facial 
erysipelas,  in  full  doses  (20  to  30  minims)  often  repeated — that  is, 
every  second,  third,  or  fourth  hour.  It  may  with  advantage  be 
prescribed  with  equal  quantities  of  glycerine,  and  in  peppermint  or 
chloroform  water.  Mr.  de  Morgan,  of  the  Middlesex  Hospital,  says 
that  this  treatment  is  most  efficacious  in  shortening  the  duration  of 
the  attack  and  securing  a  rapid  and  satisfactory  convalescence.  He 
has  given  as  much  as  an  ounce  to  an  ounce  and  a  half  of  the  official 
tincture  in  twenty-four  hours,  in  the  more  severe  forms  of  the 
disease.  The  ethereal  tincture  of  the  German  Pharmacopoeia,  which 
contains  one  per  cent,  of  ferric  chloride  in  a  mixture  of  one  part  of 
ei  her  and  three  parts  of  alcohol,  is  a  favourite  preparation  in 
Germany  under  the  name  of  "  Bestuscheff's  tincture." 

In  that  country,  however,  quinine  now  enjoys  a  higher  reputation, 
in  consequence  of  the  researches  of  Binz  a  and  the  recommendation 
of  Liebermeister.  When  given  in  doses  up  to  four  and  a  half  grains 
every  two  hours,  quinine  reduces  the  fever  aud  shortens  the  attack. 
A  long  experience  leads  me  to  recommend  that  quinine  in  such 
closes  should  be  administered,  not  in  an  acid  solution,  but  mixed 
with  milk  or  plain  water.  There  is  really  nothing  new  in  the 
quinine  treatment  of  erysipelas,  for  long  ago  a  mixture  of  ammonia 
and  bark  in  effervescence  was  regarded  as  a  sovereign  remedy. 

n  The  Elements  of  Therapeutics.  Translated  by  Edward  I.  Sparks,  M.A., 
M.B,Oxon.     London  :  J.  &  A.  Churchill.     1877.     Pages  206,  et  scq. 


ERYSIPELAS.  223 

Ninety  grains  of  carbonate  of  ammonium  in  six  ounces  of  decoc- 
tion of  bai*k,  to  be  taken  in  ounce  doses,  effervescing,  with  half  an 
ounce  of  fresh  lemon  juice  every  four  or  six  hours,  was  a  standard 
prescription. 

M.  Hallopeaua  has  employed  and  recommends  the  following 
method  in  the  treatment  of  erysipelas  with  salicylate  of  sodium : — 
1.  Application  to  the  part  of  compresses  wet  with  a  solution  of 
salicylate  of  sodium  (1  in  20)  covered  with  oiled  silk  and  frequently 
renewed.  2.  Internal  administration  daily  of  four  grammes  (3j)  of 
the  salicylate,  in  three  doses,  in  weak  grog.  M.  Bochefontaine's 
experiments  have  shown  that,  if  to  a  joint  compresses  wet  in  a 
solution  of  salicylate  of  sodium  (1  in  20)  be  applied  and  covered 
with  oiled  silk,  the  drug  will  soon  appear  in  the  urine.  Hallo- 
peau  begins  the  internal  treatment  witli  a  calomel  purge,  and 
then  gives  sulphate  of  quinine  and  salicylate  of  sodium  alternately, 
at  a  day's  interval  the  one  from  the  other. 

The  results  of  this  treatment,  observed  in  twelve  cases,  were  as 
follows: — 1.  The  temperature  was  undoubtedly  lowered  in  those 
cases  which  presented  marked  febrile  disturbance.  2.  In  most  cases 
the  duration  of  the  disease  was  much  abridged,  judging  from  the 
statement  of  Velpeau  that  twelve  days  is  the  usual  course.  In 
several  cases  the  disease  seemed  quite  promptly  controlled.  3.  Up 
to  the  time  at  which  he  wrote  the  author  had  not  observed  the 
accidents  which  have  occurred  within  his  knowledge  in  typhoid- 
fever  patients  taking  the  same  doses  of  the  remedy.  In  one  case 
there  was  a  slight  temporary  delirium,  which  may  not,  however, 
have  been  due  to  the  medicine.  The  author  recommends  suspension 
of  salicylic  acid  treatment  in  this  and  other  diseases  as  soon  as 
cerebral  disturbance  or  dyspnoea  makes  its  appearance. 

I  have  myself  followed  this  line  of  treatment  in  cases  of  erysi- 
pelas and  with  the  happiest  results,  nor  have  I  ever  seen  any 
untoward  effects  from  the  use  of  this  almost  specific  remedy. 

To  reduce  the  temperature  Volkmann  recommends  cold  baths  — 
repeated,  if  necessary,  three  or  four  times  a  day.     They  are  grateful 

a  VUnion  Medical,  May  1,  1881,  and  New  York  Medical  Journal  and  Obste- 
tricul  Review,  September,  1881. 


224  ERYSIPELAS. 

to  the  patient  and  relieve  head  symptoms,  but  do  not  control  the 
erysipelatous  inflammation.  The  bath  should  be  given  at  80°  F. 
and  for  15  or  20  minutes. 

In  ordinary  erysipelas,  alcoholic  stimulants  are  contra-indicated, 
but  in  the  severer  forms  of  the  disease  their  free  administration  is 
called  for,  subject  to  the  conditions  laid  down  in  Chapter  V., 
page  58. 

In  gastro-intestinal  disturbance,  effervescing  draughts  are  useful, 
or  small  doses  of  bicarbonate  of  sodium  with  rhubarb  and  calumba. 
Sehacht's  "Liquor  Bismuthi"  also  is  an  excellent  adjuvant.  A 
single  dose  of  calomel  (5  grains)  is  often  advantageous  in  this  con- 
dition. 

In  threatening  delirium,  opium  in  full,  but  guarded  doses,  or 
hypodermic  injections  of  morphin  are  most  valuable  remedies. 

Topical  or  Local  Treatment  has  three  ends  in  view — First,  to 
relieve  pain  and  tension ;  secondly,  to  check  the  spread  of  the 
inflammation;  thirdly,  to  destroy  the  infectious  matter  in  situ. 

The  first  indication  is  met  by  covering  the  affected  part  with 
cotton  wool  so  as  to  exclude  the  air  ;  by  dusting  it  over  with  flour, 
or  powdered  starch,  or  a  mixture  of  oxide  of  zinc  and  salicylated 
starch,  or— best  of  all  (for  when  wet,  it  does  not  cake  on  drying) — 
with  a  mixture  of  oxide  of  zinc  and  lycopodium  powder,  of  each 
half  an  ounce,  intimately  shaken  up  with  15  to  30  minims  of 
liquefied  pure  carbolic  acid.  If  these  means  fail,  the  part  should 
be  fomented  with  flannels  wrung  out  of  a  hot  decoction  of  poppies 
(Sir  Thomas  Watson),  or  covered  with  spongiopiline,  soaked  in  hot 
water  and  sprinkled  with  laudanum.  The  old-fashioned  prejudice 
against  "  wetting  the  rose"  has  long  since  been  given  up,  in  medical 
circles  at  all  events. 

Marc  See,  of  Paris,8,  employs  subnitrate  of  bismuth  as  a  dressing. 
It  is  a  preventive  as  well  as  a  curative  agent.  It  should  be  dusted 
as  a  powder  topically  over  the  solution  of  continuity,  which  is  the 
point  of  departure  of  the  malady. 

Leeches  are  contra-indicated  in  erysipelas,  because  each  leech- 

*  Paul  Lefort :  "La  Pratique  Joumaliere  des  Hdpitavm  de  Paris."  1891. 
Page  153. 


ERYSIPELAS.  225 

bite  would  be  a  trauma  or  wound  from  which  the  specific  dermatitis 
would  take  a  new  departure.  Cold  evaporating  lotions,  lead  lotion, 
and  poultices  are  supposed  to  predispose  to  gangrene  in  erysipelas. 

With  the  view  of  checking  the  spread  of  the  dermatitis,  various 
ointments  for  smearing  over  the  erysipelatous  surface  have  been 
proposed.  Such  are  mercurial  ointment  (Ricord),  and  an  unguent 
consisting  of  dried  sulphate  of  iron,  60  grains ;  glycerine,  20  minims ; 
lard,  an  ounce  and  a  half  (Alfred  Hudson). 

The  erysipelatous  patch  may  be  painted  over  with  collodion, 
mixed  with  glycerine  (1  part  to  15  parts)  or  cod  liver  oil  (Zuelzer 
and  Fenwick.)  Griscom  employed  glycerine,  because  it  dehydrates 
the  tissues  and  so  exerts  an  antiphlogistic  effects  upon  the  inflamed 
parts. 

Under  the  name  of  the  "  ectrotic  a  method,"  Higginbottom  in- 
troduced the  topical  use  of  nitrate  of  silver.  A  broad  band  of 
skin  thoroughly  washed  and  freed  from  fat,  outside  the  advancing 
line  of  inflammation,  was  cauterised  with  nitrate  of  silver  in 
substance  or  in  strong  solution  (one  in  eight  parts).  Nunneley 
and  Hasse  recommended  painting  a  cordon  half  an  inch  wide  in  the 
same  way  with  tincture  of  iodine. 

To  destroy  the  virus  in  situ,  Copland  applied  rectified  oil  of 
turpentine — a  practice  which  has  gained  the  approbation  of  Liicke, 
Borgien,  Bonfigli,  and  Zuelzer.  With  the  same  object  in  view, 
Nystrom  and  Westerland,  two  Swedish  physicians,  introduced  the 
use  of  "  aseptin,"  a  powder,  and  "  aseptin-ainykos,"  a  liquid,  com- 
posed of  boric  acid  and  oil  of  cloves.  Still  more  recently  carbolic 
acid  (phenol)  has  been  used,  and  especially  by  Hiiter  in  1874  in  the 
form  of  hypodermic  injections  of  the  strength  of  2  per  cent.,  which 
besides  checking  the  spread  of  the  erysipelas  exert  a  local  anaesthetic 
action,  which  is  very  grateful  and  beneficial. 

Wilde  got  good  results  from  injecting  hypodermically  into  the 
inflamed  skin  from  15  to  30  minims  of  a  ten  per  cent,  solution  of 
sulpho-carbolate  of  sodium.     The  local  application  of  compresses 

a  "  Ectrotic  "  (from  the  Greek  tirrpamK-ds,  belonging  to  abortion)  is  applied 
to  medicines  or  modes  of  treatment  which  tend  to  produce  the  abortion  or 
sudden  cutting  short  of  a  disease. 


226  ERYSIPELAS. 

wet  with  a  5  per  cent,  solution  of  salicylate  of  sodium,  recommended 
by  Hallopeau,  has  already  been  mentioned. 

Talamon,  of  Paris,  with  Richardson's  spray-producer  sprays  for  a 
minute  over  the  external  erysipelatous  zone,  both  within  and  on  the 
outside  of  the  swelling,  with  the  following  solution  : — 
~fy.    Hydrargyr.  perchloridi,  gr.  15^; 
Acid,  citrici,  vel  tartarici,  gr.  15^ ; 
Spt.  rectificati,  min.  lxxx. ; 
iEtheris  sulphurici,  ad  §iv. 

As  this  solution  is  caustic,  the  spray  should  not  be  directed  on 
the  eyes  or  the  neighbourhood  of  the  nostrils.  The  spray  should 
be  repeated  twice  or  thrice  daily.  This  is  the  best  treatment  for 
erysipelas  in  Talamon's  opinion.  If  it  is  employed  from  the  outset, 
the  cutaneous  inflammation  yields  from  the  first  day  and  the  attack 
ceases  on  the  fourth  day. 

In  oedema  of  the  eyelids,  bathing  with  warm  water  coloured 
with  Condy's  permanganate  of  potassium  fluid,  collyria  of  sulphate 
of  zinc  (|- 1  grain  to  an  ounce  of  rose  water  and  a  few  drops  of 
glycerine),  and  a  blister  to  the  nape  of  the  neck  as  a  derivative  are 
measures,  all  of  which  have  been  recommended  by  high  authorities. 
Trousseau  objected  to  blistering  as  establishing  a  trauma  or  wound, 
but  Graves  and  Hudson  practised  it  with  good  results. 

In  most  cases,  the  hair  should  be  cut  close  ;  in  some,  the  head 
should  be  shaved.  In  the  latter  event,  great  care  should  be  taken 
to  avoid  hurting  the  skin,  because  of  the  influence  of  traumatism. 
For  this  same  reason  the  vesicles  or  blebs  of  erysipelas  should  not 
be  punctured,  unless  gangrene  threatens. 

Sore-throat,  laryngitis,  and  oedema  of  the  glottis,  are  to  be 
prevented  or  combated  as  suggested  under  the  heading  of  scarlatina. 

Great  tension  of  the  skin  is  relieved  by  superficial  punctures  or 
incisions  and  by  warm  poulticing.  In  this  way,  also,  the  occurrence 
of  gangrene  may  be  avoided.  Should  this  serious  accident  happen, 
or  abscesses  form,  free  incisions  should  be  made,  and  the  parts 
should  be  antiseptically  dressed  and  poulticed. 

Prof.  A.  Wolfler,  of  Vienna,  recommends  the  application  of 
strips  of  adhesive  plaster  as  a  mechanical  means  of  checking  the 
spread  of  erysipelas. 


PART  III. 
THE    CONTINUED     FEVERS, 


PART  III.— THE  CONTINUED  FEVERS. 


CHAPTER   XXIV. 
General   Considerations. 

Classification  into  Exanthemata,  Continued  Fevers,  and  Intermittent 
Fevers  is  non-essential  but  convenient. — Claims  of  Typhus  and  Typhoid  or 
Enteric  Fevers  to  be  classed  as  Exanthemata.  Three  reasons  why  they  are 
not  so-classed. — Cullen's  definition  of  the  Continued  Fevers.— Murchison's 
classification  of  these  Fevers.    Objections  advanced  to  certain  of  his  statements. 

By  no  hard  and  fast  lines  are  the  fevers  we  are  about  to  study- 
separated  from  the  group  which  has  up  to  this  engaged  our  atten- 
tion. The  accepted  classification  into  Eruptive,  Continued,  and 
Intermittent  Fevers  is  one  rather  of  convenience  than  of  absolute 
necessity.  It  is,  in  fact,  to  a  large  extent  artificial  and  arbitrary. 
I  have  already  shown  that  some  authors  have,  without  hesitation, 
included  typhus  among  the  exanthemata — indeed,  "Typhus  exan- 
thematicus  "  is  one  of  the  names  by  which  this  fever  is  known  in 
Germany8,  as  well  as  in  England13 — it  is  "  Das  exanthematische 
Nervenfieber"  of  German  writers.  In  1831,  too,  Dr.  Roupell,  of 
London,  wrote  of  this  fever  as  "  Typho-rubeoloid,"  in  allusion,  no 
doubt,  to  the  resemblance  of  the  rash  to  that  of  measles.  He  and 
Peebles0  both  maintained  the  right  of  typhus  to  rank  with  the 
exanthemata. 

a  For  example,  Hildenbrand,  Ueber  den  ansteckenden  Typhus,  Wien,  1810; 
and  Schulz,  Typhus  exanthemat.icus  beobachtet  in  den  Winter monaten  des  Jahrei, 
1847-48.     Prag.  Vierteljahrsschr.  1849. 

b  For  example,  C.  West  :  Account  of  Typhus  exanthematicus  in  St.  Bar- 
tholomew's Hospital  in  1837-38.  Edinb.  Med.  and  Surg.  Journ.,  Vol.  L.,  1838. 
But  see  also  the  Edinb.  Med.  and  Surg.  Journ.,  April,  1840,  where  Dr.  West  dis- 
cusses the  very  question  whether  typhus  should  be  classed  among  the  exanthe- 
matous  Fevers,  and  decides  it  in  the  negative,  while  employing  the  term  "  Ex- 
anthematic  Typhus." 

0  Edinb.  Med.  and  Surg.  Journ.     Vol.  XLIV.,  1835. 


230  GENERAL   CONSIDERATIONS. 

Even  typhoid  or  enteric  fever  has  been  considered  an  exanthe- 
matic  fever.  In  1699  F.  Hoffmann,  of  Halle,  described  a  fever 
under  the  name  of  Febris  petechizans  vel  spuria,  in  contradistinction 
to  Febris  petechialis  vera  (or  true  typhus.)  This  fever  was  charac- 
terised by  an  insidious  commencement,  vomiting  and  purging,  and 
by  the  appearance  about  the  seventh  day  of  an  eruption  on  the 
trunk,  consisting  of  elevated  papules,  which  disappeared  completely 
upon  pressure.     Is  not  this  an  accurate  picture  of  enteric  fever? 

Why,  then,  do  we  separate  some  fevers  from  the  exanthemata 
and  group  them  together  as  "  Continued  Fevers  ?  "  Briefly,  for 
three  reasons. 

First,  because  two  of  these  fevers — simple  continued  and  relaps- 
ing fever — throw  out  no  rash  at  all.  Therefore,  in  no  way  could 
they  be  classed  with  the  exanthemata. 

Secondly,  because  the  occurrence  of  a  rash,  or  eruption,  is  much 
less  constant  in  both  typhus  and  typhoid  than  it  is  in  the  case  of 
eruptive  fevers,  properly  so-called.  It  is  true  that  Murchison  says 
the  eruption  of  typhus  is  very  rarely  absent.  During  twenty-three 
years  it  was  noted  in  93*2  per  cent,  of  the  18,268  cases  admitted 
into  the  London  Fever  Hospital.  Murchison  thinks  this  estimate 
too  low,  and  says  that  in  1864  it  was  noted  in  all  but  55  out  of 
2,493  cases,  or  in  97'77  per  cent.  But  we  should  not  lose  sight  of 
an  important  point  bearing  on  this  matter,  which  is  that  the  cases  ad- 
mitted to  hospital  are,  generally  speaking,  those  in  which  a  positive 
diagnosis  of  typhus  had  been  made  before  admission,  and  most  pro- 
bably because  of  the  presence  of  the  characteristic  rash,  which 
Murchison  himself  says  is  pathognomonic.  The  slight  and  non- 
maculated  cases  are  left  behind  in  their  homes,  and  so  do  not  share 
in  the  elaboration  of  statistical  results.  Many  years  experience  at 
Cork-street  Fever  Hospital  has  convinced  me  that  the  typhus  rash 
is  often  absent,  at  all  events  in  children.  Murchison  himself  admits 
that,  "  in  children  it  is  oftener  absent  than  in  adults." 

As  for  enteric  fever,  the  eruption  is  by  no  means  invariably 
present.  In  the  London  Fever  Hospital,  in  twenty-three  years,  it 
was  detected  in  only  76*92  per  cent,  of  the  cases,  Murchison  remark- 
ing as  to  this,  that  •'  the  fact  of  the  spots  not  being  observed  was, 


GENERAL    CONSIDERATIONS.  231 

perhaps,  due  to  their  not  having  been  looked  for  with  sufficient 
care."  According  to  Edmund  Parkes,a  spots  are  absent  in  2<>  per 
cent,  of  the  cases  of  enteric  fever — a  result  which  very  fairly  agrees 
with  the  statistics  at  the  London  Fever  Hospital. 

Thirdly — Whereas  the  rashes  of  smallpox,  measles,  scarlatina, 
and  erysipelas  are  shown,  both  clinically  and  histologically,  to  be 
true  inflammations  of  the  skin  (dermatitides),  the  same  cannot  be 
alleged  of  either  the  rose-spots  of  typhoid  or  the  maculae  and  petechia- 
of  typhus.  Both  rose-spots  and  macula  do  not  as  a  rule  pass 
the  stage  of  hyperaemia,  and  the  petechias  are,  in  Murchison's  own 
words,  u  due  to  an  infiltration  of  dissolved  haematin  into  the  tissue 
of  the  cutis." 

Cullen's  definition  of  the  continued  fevers  runs  as  follows : — 
"Febres,  sine  intermissione,  nee  miasmate  paludum  ortse,  sed 
cum  remissionibus  et  exacerbationibus,  parum  licet  notabilibus, 
perstantes:  paroxysmis  quovis  die  binis"  ("Fevers  which  ran 
their  course  without  intermission,  and  do  not  arise  from  a  paludal 
miasm,  but  continue  with  remissions  and  exacerbations,  which  are 
not,  however,  very  marked  :  two  paroxysms  being  observed  in  the 
course  of  any  given  day  of  twenty-four  hours.") 

Murchison's  Classification  of  the  Continued  Fevers  of  Great 
Britain  and  Ireland  is  the  following : — 

A.  Non-Specific.  I.  Simple  Fever,  caused  by  exposure  to  the 
sun,  fatigue,  surfeit,  &c. 

II.  Endemic  (Enteric,  Typhoid,  or  Pythogenic), 
the  poison  being  contained  in  drinking 
water,  emanations  from  sewers,  &c. 

I  Typhus,  caused  by  contagion  or  by 
the  concentrated  exhalations  from 


B.  Specific 


IIL  &  IV. 

_  . .,      .       <       squaua  numan  beings. 
Epidemic     )  „ 

Relapsing  Fever,  arising  from  con- 
tagion or  famine. 

In  this  Table,  two  points  may  fairly  be  criticised  as  being  too 
dogmatic  and  certainly  open  to  question.     These  are — the  unqua- 

fl  Association  Medical  Journal,  1856,  p.  993. 


232  GENERAL    CONSIDERATIONS. 

lifted  use  of  the  term  "  Non-specific "  in  connection  with  the 
intimate  nature  of  Simple  Fever,  and  the  doctrine  that  typhus 
may  arise  de  novo,  that  is,  may  be  spontaneously  generated  by  the 
concentrated  exhalations  from  squalid  human  beings. 

If  simple  fever  is  absolutely  non-specific  in  its  origin,  it  should 
find  no  place  among  a  group  of  acute  infective  and  essential  fevers, 
which  from  the  very  nature  of  the  case  are  to  be  considered  as 
specific. 

Again,  the  doctrine  of  the  spontaneous  origin  of  a  febrile  disease 
like  typhus  lands  us  in  the  midst  of  greater  difficulties  than  those 
which  such  a  doctrine  is  intended  to  solve.  It  is  opposed  to  all 
analogy  and,  in  fact,  it  is  quite  unnecessary  if  we  bear  in  mind 
the  marvellous  vitality  of  "  resting  spores  "  and  the  influence  which 
a  powerful  combination  of  predisposing  causes  may  have  in  calling 
into  action  the  proper  exciting  cause  of  a  catching  or  infectious 
(contagious)  disease  like  typhus. 

These  questions  will  come  up  for  further  consideration  in  our 
study  of  each  of  the  Continued  Fevers  in  the  succeeding  chapters. 
The  order  in  which  I  propose  to  describe  the  different  fevers  is — 
(1)  Simple  Fever,  (2)  Typhus,  (3)  Eelapsing  Fever,  (4)  Typhoid 
or  Enteric  Fever. 


233 


CHAPTER   XXV. 
Febricula,  or  Simple  Fever. 

Nomenclature. — Definition. — ^Etiology  and  History. — Probably  of  specific 
origin, like  the  other  fevers — probably  auto-infective —Clinical  History  :  Four 
Forms — 1.  Ephemera  ;  2.  Synocha,  or  Acute  Inflammatory  Fever  ;  3.  Ardent 
Continued  Fever  of  the  Tropics  ;  4.  Asthenic  Simple  Fever. — Diagnosis. — 
Prognosis. — Pathology. — Treatment. 

Nomenclature. — Simple  Continued  Fever  {Lot.  Febris  Continua 
Simplex,  Lieutaud,  1776).  Syn. — Acute  Continual  Fever  (Laugrish, 
1735);  Simple  Inflammatory  Fever  (Huxham,  1739;  Fordyce, 
1791).  Germ.  Entziindungsfieber.  Fr.  La  Fievre  Inliammatoire. 
Ital.  Febbre  Inflammatoria.  Gk.  Kavao<;  (Hippocrates).  Spanish, 
La  Calentura  (Piquer,  1751).  Ardent  Fever  [of  the  Tropics] 
(Burnett,  1812;  Sir  Ranald  Martin,  1841;  Copland,  1844); 
Synocha  (Cullen);  Fievre  Synoque  (Davasse,  1847). 

From  its  duration,  this  fever  received  many  names,  of  which 
the  chief  are: — Synocha  septimo  die  soluta  (Hoffmann,  1700); 
Febris  ephemera  (Riverius,  1623  ;  Sennertus,  1641;  de  Sauvages, 
1760);  Ephemera  simplex  (Boerhaave,  1738);  Diary  Fever 
(Strother,  1728).  Germ.  Das  eintagige  Fieber.  Fr.  Fievre 
Eph^mere.     Ital.  Effimero.     Span.  Efemera. 

From  its  causes,  it  was  described  by  Boissier  de  Sauvages  (1760) 
as  "  Ephemera  a  Frigore  "  and  "  Ephemera  a  Calore  ;  "  and  by 
Scriven,  in  1857,  as  ''  Sun  Fever." 

The  term  "Febricula"  is, of  course,  the  diminutive  of  "  Febris," 
and  has  reference  to  its  comparatively  trivial  nature  and  short 
duration. 

It  is  also  sometimes  called  "  Herpetic  Fever,"  from  the  frequency 
with  which  crops  of  herpes  break  out  during  its  course,  especially 
about  the  nostrils  and  mouth,  and  on  the  lips. 

Definition. — An  acute  Fever,  said  to  be  non-contagious,  occur- 
ring sporadically  in  general,  but  occasionally  assuming  an  epidemic 


234  SIMPLE    FEVER. 

form,  arising  from  exposure  to  the  sun,  over-fatigue,  a  surfeit, 
inebriety,  running  a  course  of  from  one  to  seven,  or  rarely  ten  days, 
without  eruption,  but  with  marked  febrile  symptoms,  tongue  furred 
but  moist;  terminating  critically  with  profuse  sweating;  often 
accompanied  by  herpetic  eruptions ;  rarely  fatal  unless  in  the 
Tropics  ;  no  specific  lesion  in  fatal  cases. 

JEtiology  and  History. — This  form  of  fever  has  been  identified 
since  the  time  of  Hippocrates.  In  the  paroxysm  of  any  fever  there 
are  three  stages — (1.)  The  cold  stage,  ushered  in  by  rigors  (also 
called  the  pyrogenetic  stage)  ;  (2.)  the  hot  stage,  or  stage  of  reaction 
(the  fastigium,  or  acme)  ;  and  (3.)  the  sweating  stage,  or  crisis  (de- 
fervescence). In  simple  fever  these  may  all  occur  and  be  com- 
pleted within  twenty-four  hours.  Hence  such  names  for  the  disease 
as  "ephemeral*  fever,"  "  diary  fever,"  "das  eintagige  Fieber,"  and 
so  on. 

In  1728,  Strother  described  a  "  diary  fever,"  distinct  on  the  one 
hand  from  "  spotted  fever"  (typhus),  and  on  the  other  from  "slow 
fever "  (typhoid).  The  diary  fever,  he  said,  resulted  "  from  hard 
drinking,  or  too  great  heat  of  the  sun,  or  from  a  little  cold ; "  it 
needed  "  little  help  from  physic,"  and  it  did  "  not  last  above  three 
or  four  days." 

There  can  be  no  doubt  that  the  term  "  Simple  Fever  "  has  become 
a  refuge  of  many  cases  of  mild  typhus  (T.  levissimus,  of  Hilden- 
brand)  and  ill-defined  typhoid  fever  or  relapsing  fever  without  the 
relapse,  and  so  the  sepai'ate  identity  of  febricula  has  been  called  in 
question.  But,  as  we  have  seen,  from  the  earliest  times  the  exist- 
ence of  this  disease  has  been  recognised.  Its  ordinary  causes  are 
exposure  to  great  heat  or  cold,  surfeit  or  inebriety,  gastric  derange- 
ment, imperfect  excretion,  and  mental  or  bodily  fatigue. 

It  is  probable,  but  not  yet  proved,  that  simple  continued  fever 
may  result  from  some  specific  contagion  as  yet  not  isolated. 
Analogy,  in  the  first  place,  points  in  this  direction.  Next,  although 
this  fever  is  a  sporadic  disease,  as  it  is  commonly  observed  in 
temperate  climates,  yet  epidemics  of  it  have  been  described  from 
time  to  time — for  example,  by  Ingrassias,  of  Palermo,  as  occurring 
tt  Gk.  tin,  upon  ;  Vi/xepa,  a  day. 


SIMPLE    FEVER.  235 

in  Sicily  in  1557;  by  Hoyer  at  Mulhausen  towards  the  end  of 
summer  in  1700.  In  India,  the  "Ardent  Fever,"  which  according 
to  Murchison  is  only  the  tropical  variety  of  simple  fever,  often 
assumes  an  epidemic  form  during  the  hot  dry  season.  Again,  the 
whole  cyclical  course  of  the  malady  almost  proves  its  specific 
origin,  and  lastly,  one  variety  of  it — the  "  feverish  cold  "  or 
"  acute  catarrh  " — is  certainly  infectious,  or  "  taking,"  in  a  high 
degree. 

It  may  be  that  in  most  cases  the  virus  of  this  form  of  fever  is 
inbred  in  the  body,  rather  than  introduced  into  the  system  from 
without — that  it  is  an  auto-infective,  or  autochthonous8-  disease. 

Children  are  most  liable  to  suffer  from  febricula,  adolescents  are 
less  so,  and  the  infection  becomes  more  and  more  infrequent  as 
middle  life  is  reached,  and  as  old  age  approaches. 

Clinical  History. — Apart  from  the  Ardent  Continued  Fever  of 
the  Tropics,  and  another  variety  to  which  Murchison  gives  the 
name  of  Adynamic  Simple  Fever,  simple  continued  fever  shows 
itself  under  two  principal  forms — true  Ephemera,  and  Synocha  or 
Inflammatory  Fever. 

1.  In  the  first  or  ephemeral  form,  the  patient  is  suddenly  seized 
with  chills  or  rigors,  followed  by  quick  full  pulse,  flushed  face,  dry 
hot  skin,  loss  of  appetite,  thirst,  and  headache.  The  limbs  feel 
sore,  as  if  bruised,  the  bowels  are  confined,  and  the  tongue  is  coated 
but  moist.  The  urine  is  scanty,  high-coloured,  dense  (Spec.  Grav. 
1025-35),  and  towards  the  close  of  the  fever  deposits  urates 
(lithates)  in  abundance.  The  symptoms  pass  off  in  twelve,  twenty- 
four,  or  thirty-six  hours,  with  profuse  sweating,  and  the  patient 
who  has  been  restless,  or,  if  a  child,  perhaps  delirious,  falls  into  a 
tranquil  sleep. 

2.  In  the  synochalb  form- — so-called  from  its  continuance — the 
febrile  movement  is  more  prolonged  and  the  symptoms  are  more 
acute  and  severe,  while  they  belong  to  the  same  category  as  before. 
From  time  immemorial  a  tendency  of  this  fever  to  terminate  on  odd 

a  Autochthonous,  indigenous.  From  Gk.  avT6x^a>v,  sprung  from  the  land  itself, 
of  native  stock. 

I.e.,  continued;  from  Gk.  awoxh,  a  holding  together. 


236  SIMPLE    FEVER. 

days — the  3rd,  5th,  7th,  or  9th — has  been  observed,  so  that  these 
are  sometimes  called  critical  days. 

Modes  of  Crisis. — The  crisis  in  ephemera  and  synocha  may  take 
place  in  one  or  more  of  many  ways — namely,  sweating,  copious 
epistaxis  or  nose-bleed,  haemorrhage  from  the  womb  or  rectum,  an 
attack  of  vomiting,  a  sudden  diarrhoea,  diuresis  with  a  dense  deposit 
of  lithates  in  the  urine,  or  the  development  of  a  crop  of  herpetic 
vesicles  on  the  lips  (herpes  labialis)  or  about  the  nostrils,  hence  the 
term  "  Herpetic  Fever." 

Simple  Fever  is  not  attended  by  any  skin-eruption.  In  a  few 
cases  Davassea  observed  pale  bluish  spots — the  taches  bleudtres  of 
French  writers — which  are  also  occasionally  met  with  in  typhoid 
fever,  acute  pneumonia,  and  other  diseases.  There  is  nothing 
characteristic  about  these  markings,  which  are  supposed  by  Striimpellb 
and  German  writers  generally  to  be  connected  with  the  irritation 
of  lice.  This  view  is  gaining  ground  in  British  Medical  literature, 
for  Jamieson,  writing  in  the  British  Journal  of  Dermatology  (Volume 
I.,  No.  10),  includes  among  the  rarer  effects  of  the  presence  of 
pediculi  the  development  of  maculce  c&rulea}  (taches  bleuatres)  upon 
the  skin.  Facing  page  516  of  the  third  edition  of  Murchison's 
Treatise  on  the  Continued  Fevers  there  is  a  beautiful  tinted  litho- 
graph, representing  these  taches  bleuatres  in  enteric  fever.  In 
several  instances  he  saw  them  distributed  along  the  course  of  the 
small  subcutaneous  veins. 

The  Ardent  Continued  Fever  of  the  tropics  is  merely  an  ex- 
aggerated form  of  the  synocha  of  Great  Britain  and  Ireland. 
Murchison  gives  a  graphic  account  of  it  as  he  observed  it  among 
the  European  troops  at  Calcutta  in  1853  and  in  Burmah  in  1854. 
In  many  cases  the  symptoms  commenced  immediately  after  in- 
cautious exposure  to  the  direct  rays  of  the  sun.  Hence  Scriven's 
name  for  it:  "Sun  Fever."0  It  appears  to  be  a  very  formidable 
fever  indeed.     About  the  fourth  or  fifth  day  there  was  often  acute 

a  Des  Fievres  Ephemere  et  Synoque.     Paris,  1847.     P.  23. 

b  Text-book  of  Medicine.  By  Adolf  Striimpell.  English  Translation.  London  : 
'H.K.Lewis.     1887.     Page  16. 

0  J.  B.  Scriven :  On  Indian  Fevers.  Indian  Annals  of  Medical  Science, 
No.  8,  1857. 


SIMPLE    FEVER.  237 

delirium,  followed  by  more  or  less  unconsciousness,  contracted 
pupils,  and  sometimes  complete  coma.  Between  the  sixth  and  the 
ninth  day,  death  took  place  by  coma,  or  there  was  a  copious  per- 
spiration, followed  by  a  rapid  fall  of  the  pulse,  an  increased  flow 
of  urine,  an  abundant  deposit  of  urates,  and  convalescence.  The 
subsidence  of  the  fever  was,  however,  occasionally  followed  by 
sudden,  or  even  fatal  collapse.8. 

The  Adynamic  or  Asthenic  Simple  Fever  may  run  on  for  two 
or  three  weeks,  with  increasing  weakness.  Murchison  frequently 
observed  attacks  of  this  kind  after  great  mental  or  bodily  fatigue, 
and  Alfred  Hudson b  had  a  similar  experience.  "  At  the  same 
time,"  says  Murchison,  "  it  must  be  remembered  that  cases  of  this 
sort  are  never  fatal,  and  that  enteric  fever  often  assumes  characters 
very  like  those  now  described." 

Diagnosis. — This  is  often  a  matter  of  difficulty,  or  even  impos- 
sible. From  typhus  and  typhoid  fevers  it  is  ultimately  distin- 
guished by  its  short  duration  and  the  absence  of  an  eruption.  An 
outbreak  of  herpes  on  the  face  about  the  fifth  day  of  a  feverish 
attack  would  suggest  simple  fever  in  the  absence  of  pneumonia  or 
of  typhus.  Resembling  the  first  paroxysm  of  relapsing  fever  by 
its  intensity,  simple  fever  is  distinguished  from  that  malady  by  the 
comparative  insignificance  of  the  muscular  and  arthritic  pains 
which  accompany  it,  and  by  the  absence  of  enlargement  of  the 
spleen  and  liver,  and  of  jaundice.  Besides,  it  occurs  at  times  and 
in  places  other  than  those  selected  by  relapsing  fever. 

Prognosis  is  almost  invariably  favourable  in  this  country,  unless 
some  complication  should  arise.  The  ardent  fever  of  the  tropics 
is  stated  to  be  a  serious  and  often  fatal  disease. 

Pathology. — There  is  no  special  lesion.  Murchison  observed 
great  congestion  of  all  the  internal  organs  in  the  fatal  cases  of 
ardent  fever  examined  in  India. 

Treatment. — The  simple  continued  fever  of  this  country  re- 
quires no  special  treatment  beyond  rest  in  bed,  a  suitable  diet, 

a  MurchiRon :  On  the  Climate  and  Diseases  of  Burmah.  Edinb.  Med.  and 
Surg.  Journ.,  Jan.  and  April,  1855. 

b  Lectures  on  the  Study  of  Fever.     Dublin  :  1867.     P.  262. 


238  SIMPLE    FEVER. 

and  attention  to  the  bowels,  kidneys,  and  skin.  As  to  the  ardent 
fever  of  the  tropics,  all  writers  on  Indian  diseases  advise  venesec- 
tion or  leeches  to  the  head,  followed  by  cold  effusion,  the  continued 
application  of  cold  to  the  shaven  scalp,  purgatives,  and  diaphoretics.8. 
For  the  asthenic  form  Murchison  recommends  quinine  and  the 
mineral  acids,  with  a  nutritious  diet  and  wine. 

a  Cf.  Morehead  :  Clinical  Researches  on  Diseases  in  India,  1860.  Second 
EditioD.  Page  166.  Also,  Sir  Kanald  Martin  :  Influence  of  Tropical  Climates. 
1856.     Page  208. 


239 


CHAPTER  XXVI. 
Typhus  Fever. 

Nomenclature  —  Literature  —  Definition  —  Geographical  Distribution — 
^EnoLOQY — Exciting  and  Predisposing  Causes — Facts  known  relative  to  the 
Specific  Poison  of  Tjphus  :  1.  Modes  of  infection  ;  2.  Its  striking  distance 
not  great  ;  3.  Poison  readily  absorbed  by  "  fomites  ; "  4.  Period  of  infec- 
tiousness :  Convalescence  ;  5.  Non-inoculable  ;  6.  One  attack  confers  immunity  ; 
7.  Of  light  specific  gravity ;  8.  Destroyed  by  dry  heat ;  9.  Typhus  not  an 
epizootic — Murchison's  doctrine  of  the  spontaneous  generation  of  typhus — 
Proofs  of  its  infectiousness — Arguments  for  and  against  its  spontaneous 
origin — Predisposing  Causes  :  Sex,  Age,  Season,  Temperature  and  Moisture 
in  the  Atmosphere,  Occupation,  Idiosyncracy,  Intemperance,  Bodily  Fatigue, 
Mental  Fatigue  and  Depressing  Emotions,  Previous  Illness,  Recent  Residence 
in  an  infected  district,  Overcrowding  and  defective  Ventilation,  Destitution 
and  deficient  Alimentation — Conclusions. 

Nomenclature. — No  fewer  than  98  names  for  this  form  of  Con- 
tinued Fever  are  specified  by  Murchison  in  his  elaborate  account  of 
the  disease.     Of  these  I  can  here  give  only  a  selection  :  — 

Typhus.— (Boissier  de  Sauvages,  1760;  Cullen,  1769;  and  all 
modern  British  writers)  Gk.  Tv<f>o<i,  smoke,  mist,  fog.  The  term 
was  employed  by  Hippocrates  to  define  a  confused  state  of  the 
intellect,  with  a  tendency  to  stupor  ("stupor  attonitus"),  and  in 
this  sense  it  is  aptly  applied  to  typhus  with  its  slow  cerebration 
and  drowsy  stupor. 

Previous  to  the  time  of  Boissier  de  Sauvages  (1760)  typhus  was 
known  as  "  Pestilential "  or  "  Putrid  Fever,"  or  by  some  name 
suggested  by  the  eruption,  or  expressive  of  the  locality  in  which  it 
appeared,  as  "  Camp,"  "  Jail,"  "  Hospital,"  or  "  Ship  Fever  "  (Mur- 
chison). 

From  its  contagious  nature  it  was  called  "  Parish  Infection  " 
(English  Bills  of  Mortality,  1600-1700),  "Infectious  Fever" 
(Lind,  1763),  "  Contagious  Fever"  (Bateman,  1818),  "  Tifo  con- 
tagioso  "  (Rossi,  1819),  "Der  ansteckende  Typhus  "  (Hildenbrand, 
1810). 


240  TYPHUS   FEVER. 

From  its  prevalence  in  epidemics,  it  received  the  name  of 
"  Febris  epidemica "  (J.  Burserius,  1625),  "  Febbre  epidemica" 
(Rasori,  1813). 

From  the  characteristic  rash,  it  was  described  as  "  Morbus 
pulicaris"a  (Cardanus,  1545);  "Febris  petechialis " b  (N.  Massa 
1556  ;  Sennertus,  1641,  and  others),  "Febbre  petecchiale"  (Rasori, 
1809);  '-Spotted  Fever"  (Strother,  1729;  Short,  1749);  "Das 
Fleckenfieber"  (Reuss,  1814)  ;  "  Petechial  Fever"  (Peebles,  1835) ; 
"Exanthematic  Typhus,"  "Petechial  Typhus,"  "Typho-Rubeoloid" 
(Roupell,  1831.)  Hirsch0  informs  us  that  Fracastori,  who  flourished 
at  Verona  from  1483  to  1553,  and  whose  most  valuable  work, 
"  De  Morbis  Contagiosis,"  contains  the  first  description  of  typhus, 
based  on  his  Veronese  experiences,  mentions  the  epidemic  under 
the  name  of  "Lenticular"  (freckles),  "Puncticula,"  or  "Peticulae," 
as  a  contagious  disease  indigenous  in  Cyprus  and  adjoining  islands, 
well  known  to  the  older  physicians,  but  now  observed  for  the  first 
time  in  Italy.  Fracastori's  account,  "  De  curatione  febrium  quce 
Lenticulce  vocantur"  begins  as  follows: — "  Nunc  de  particularibus 
magis  agamus,  ac  primum  de  curatione  earum  febrium  pertracte- 
mus,  qua?,  qu6d  non  vere  pestilentes  sunt,  maligna?  tantum  dicuntur, 
quales  illse  fuere  quae  annis  1505  et  1528  tarn  large  apparuere, 
quas  alii  Lenticulas,  alii  puncticula,  vel  peticulas  appellavere  :  de 
quibus  diligentissime  agendum  videtur,  quoniam  ssepe  per  epi- 
demias  revertuntur,  ssepe  sine  iis  enascuntur,  ac  nunc  etiam  per 
Italiam  visuntur,  certis  autem  regionibus  maxime  familiares."  d 

From  the  presence  of  cerebral  symptoms  it  was  called  "  Typhus 
Comatosus"  by  de  Sauvages  in  1760,  and  "Brain  Fever"  by 
various  authors. 

From  the  tendency  to  prostration  which  accompanies  typhus, 
Pinel,  in  1798,  described  it  under  the  names  "Fievre  Ataxique  " 
and  "  Fievre  Adynamique." 

a  "  Of,"  or  "belonging  to,  Jieas,"  from  Lat.  pulex,  a  flea. 

b  From  Italian  petecchio,  a  flea-bite. 

c  Handbook  of  Geographical  and  Historical  Pathology.  New  Syd.  Soc,  1883. 
Vol.  I.,  page  548. 

d  Hieronymi  Fracastorii  Veronensis  Operum  Pars  Prior.  Genevse  :  Typis 
Jacobi  Stoer.     MDCXXXV1L,  page  228. 


TYPHUS    FEVER.  241 

From  its  prevalence  in  time  of  war,  it  was  called  'Testis 
Bellica,"  "  Morbus  Castrensis  "  (Sennertus),  "  Typhus  Castrensis  " 
(de  Sauvages,  1760),  "Camp  Fever"  (Grant,  1775),  "  Die  Kriegs- 
pest"  (Hufeland  and  Reuss,  1814).  It  was  the  first  and  chief  of 
the  "  Leaguer  Sicknesses"  of  the  old  Irish  chroniclers. 

From  its  prevalence  in  prisons,  hospitals,  and  ships,  it  received 
among  other  titles  those  of  "  Jayl  Fever"  (Pringle,  1750;  John 
Howard,  1784),  "Typhus  Carcerum"  (de  Sauvages,  1760),  "Maladie 
des  Prisons,"  "  Febris  Nosocomialis  "  (Burserius,  1785),  "  Fievre  des 
Hopitaux,"  "Ship  Fever"  (Lind,  1763),  "Infectious  Ship  Fever" 
Blane,  1789). 

From  its  supposed  mode  of  origin  from  overcrowding,  Laycock, 
in  1861,  invented  for  it  the  name  "  Ochlotic  Fever"  (Gk.  o^Xo^ 
a  crowd). 

An  old  Irish  designation  for  it  was  "  Irish  Ague," a  and  in 
Ireland  also  it  was  often  called  "  Catarrhal  Typhus,"  from  the 
common  presence  of  bronchial  catarrh  as  a  complication.  In 
Germany  it  is  sometimes  called  "  Der  irische  Typhus,"  because 
it  used  to  be  so  prevalent  in  Ireland. 

The  synonyms  for  typhus  most  commonly  used  in  the  principal 
modern  European  languages  are  as  follows : — Germ.  Fleckfieber, 
Flecktyphus ;  French,  Typhus  Exanthdmatique ;  Ital.  Dermo-tifo, 
Typho  Esantematico  ;  Spanish,  Tif us,  "  El  Tabardillo  "  or  "  Tabar- 
diglio"  (from  tabardo,  a  cloak  of  dark  cloth  worn  by  the  peasantry 
in  Spain) ;  Dutch,  Vlekkoorts,  Kwaadardigekoorts  (i.e.,  malignant 
fever)  ;  Swedish,  Flacktyf  us ;  Norwegian  or  Danish,  Nervefeber, 
Exantematisk  Tyfus. 

Definition. — An  acute,  specific,  highly  infectious  fever,  which 
prevails  in  epidemics,  particularly  in  times  of  destitution  and  in  the 
presence  of  overcrowding  with  deficient  ventilation.  It  is  charac- 
terised by  a  sudden  onset  with  marked  nervous  symptoms,  rheuma- 
toid pains,  rigors,  and  headache.  A  peculiar  rubeoloid  rash  appears 
most  commonly  on  the  fifth  day  of  the  disease.  This  consists  of 
slightly  elevated  spots,  at  first  deleble  on  pressure  (macules),  after- 

c  Cf.  Dr.  Gerard  Boate,  Physician  to  Cromwell's  Army.  Natural  History  of 
Ireland.     Dublin.     1642. 


242  TYPHUS   FEVER. 

wards  persistent  and  darker  (petechia).  There  is  early  prostration 
of  both  nervous  system  (ataxia)  and  muscular  system  (adynamia). 
In  the  second  week  delirium  is  commonly  present,  sometimes  of 
an  acute  and  noisy  type,  but  oftener  of  a  low  wandering  kind,  and 
there  is  a  tendency  to  stupor  or  coma.  The  fever  terminates  by  a 
crisis  which  generally  happens  on  or  about  the  fourteenth  day. 
In  fatal  cases  no  specific  lesion  is  found  beyond  a  widespread 
congestion  and  "  dissolution  of  the  blood." 

Literature. — Among  authors  who  have  described  this  fever,  Sir 
John  Pringlea  occupies  a  foremost  place.  He  gave  an  excellent 
description  of  the  epidemics  observed  in  the  British  Army  in  1742 
and  1745.  Von  Hildenbrand's  classical  work  on  Contagious 
Typhus b  gives  a  complete  account  of  the  epidemic  during  time  of 
war.  The  work  of  Rasoric  is  interesting  from  a  historical  point 
of  view.  An  excellent  account  by  Virchow  himself  of  the  typhus 
of  Upper  Silesia  is  to  be  found  in  the  second  volume  of  Virchow's 
Archiv  for  1849,  and  equally  valuable  is  Lindwurm's  description 
of  typhus  in  Ireland.3  The  best  general  descriptions  are  those  of 
Murchison,e  Griesinger,f  and  Lebert.g  The  relations  and  con- 
ditions of  the  spread  of  the  disease  are  ably  discussed  by  A.  Hirsch 
in  his  "  Handbook  of  Historical  and  Geographical  Pathology."  h 

Geographical  Distribution. — "The  history  of  typhus,"  writes 
Hirsch,1  "  is  written  in  those  dark  pages  of  the  world's  story  which 
tell  of  the  grievous  visitations  of  mankind  by  war,  famine,  and 

a  Observations  on  Diseases  of  the  Army.  London,  1752.  Also  Observations 
on  the  Nature  and  Cure  of  Hospital  and  Jail  Fevers.     London,  1750. 

b  Ueber  den  ansteckenden  Typhus.      Wien.   1815. 

c  Storia  delta  Febr.  petech.  di  Genova.     Milano,  1813. 

a  Der  Typhus  in  Irland.     Erlangen,  1853. 

e  Text-Book  of  the  Continued  Fevers  of  Great  Britain.  London:  Longmans, 
Green  &  Co.     Third  Edition,  1884. 

'  Archiv.  der  Heilkunde,  1861.  Vol.  II.,  p.  557,  and  Virchow's  Handb.  der 
speciellen  Pathologic  und  Therapie.  II.  2  Abth.  Art.,  "  Infections  Krank- 
heiten." 

8  Von  ZiemBsen's  Cyclopaedia  of  the  Practice  of  Medicine.  Art..  "  Typhus 
Fever." 

b  New  Syd.  Society.     London  :  H.  K.  Lewis. 

1  Handbook  of  Geograph.  and  Hist.  Pathology.  New  Syd.  Soc.  1883.  Vol. 
L,  page  545. 


TYPHUS    FEVER.  243 

misery  of  every  kind."  Typhus  from  time  to  time  has  prevailed 
in  all  parts  of  Europe,  but  it  has  its  peculiar  habitat  in  Great 
Britain  and  Ireland,  and  in  Russia.  It  has  been  very  infrequent  in 
France  of  late  years.  The  Irish  race  seems  to  be  especially  prone 
to  the  disease,  most  probably  from  the  habits  and  comparative 
poverty  of  this  people.  "  It  is  a  fact,"  says  Graves,8,  "  that  typhus 
is  more  prevalent  in  this  country  (Ireland)  than  in  any  other 
European  nation."  Popham b  says  it  "  smoulders  on  until  some 
spark  kindles  it  into  a  flame." 

In  the  United  States  and  British  North  America,  typhus  has 
prevailed  epidemically  at  various  times.  It  is  hardly  known  in 
Australia,  New  Zealand,  India,  Africa,  or  the  tropical  parts  of 
America.  Murchison  is  of  opinion  that  the  so-called  "  Oriental 
Plague"  ("Bubonic  Fever")  is  perhaps  the  typhus  of  warm 
climates.  Typhus  is  mostly  a  disease  of  the  Temperate  and  Cold 
Zones — a  fact  which  is  in  some  measure,  at  all  events,  brought 
about  by  the  mode  of  living  adopted  by  people  living  in  cold 
climates.  They  congregate  together  in  badly  ventilated  houses 
rather  than  live  an  open-air  life.  "  The  idea  that  overcrowding  in 
filthy  and  unventilated  rooms  affords  the  essential  condition  for  the 
development  of  typhus-foci  and  for  the  spread  of  the  disease,  has 
been  completely  borne  out  by  the  experience  of  all  times  " — these 
are  Hirsch's  own  words. 

Epidemics  of  typhus  are  yearly  becoming  more  and  more  rare. 
The  most  recent  recorded  outbreak  is  one  which  occurred  in 
Sheffield  in  1890,  and  was  described  by  Dr.  Thomson  in  Public 
Health  (Vol.  III.,  p.  17.) 

iEtiology. — This  subject  will  be  most  conveniently  considered 
under  the  usual  headings — the  exciting  and  predisposing  causes 
of  the  fever. 

I.  In  all  cases,  without  exception,  typhus  arises  from  the  recep- 
tion into  the  system  of  a  specific  poison — the  virus,  or  contagium 
of  the  disease.  Of  the  intimate  nature  of  this  poison  we  are  still 
profoundly  ignorant. 

*  Lon.   Med.  Gazette.     January  19,  1837.     Page  571. 

b  Dubl.  Quarterly  Journal  of  Med.  Sccence.    May,  1853.    Vol.  XV.,  page  290. 


244  TYPHUS    FEVER. 

Dr.  Cayley,  the  Editor  of  the  third  edition  of  Murchison's 
"Treatise  on  the  Continued  Fevers  of  Great  Britian,"  says,  that 
"judging  from  analogy  with  relapsing  fever  and  other  con- 
tagious diseases,  it  seems  probable  that  typhus  is  due  to  a  specific 
microbe  which  requires  conditions  of  overcrowding  and  imperfect 
ventilation  to  develop  its  virulent  and  contagious  properties." 

In  1868,  Halliera  announced  his  discovery  of  a  typhus  fungus 
(Rhizoporus),  but  it  has  not  been  confirmed.  In  1873,  Zuelzerb 
claimed  to  have  obtained  "  positive  results  "  from  infection -experi- 
ments in  animals,  but  there  is  no  evidence  that  the  disease  produced 
in  the  animals  experimented  on  was  typhus.  In  1883,  Mottc 
described  actively  motile  dumb-bell  cocci  in  the  blood,  and  plugs  of 
cocci  in  the  lymphatics  of  the  heart,  in  cases  of  typhus  fever. 
Lastly,  Hlava,d  in  20  out  of  33  cases  of  typhus  examined  after 
death,  and  in  2  out  of  10  cases  examined  during  life,  found  a 
peculiar,  well-defined  bacterium,  to  which  he  gives  the  name  of 
Streptobacillus.  It  was  present  only  in  the  blood.  Injections  into 
mice,  rabbits,  cats,  and  pigeons  were  followed  by  no  result.  Young 
pigs  responded  with  acute  febrile  manifestations  and  a  red  exanthem. 
Hlava  thinks  it  not  improbable  that  the  streptobacillus  in  question 
may  be  the  cause  of  typhus  fever,  although  absolute  proof  is 
wanting.  Nothing  definite,  however,  has  as  yet  resulted  from  these 
and  similar  researches. 

Nevertheless,  there  are  certain  interesting  facts  which  we  do 
know  respecting  the  typhus  poison. 

1.  Actual  contact  with  the  sick  is  not  essential  for  the  trans- 
mission of  this  fever.  The  materies  morbi  is  cast  off  by  the  breath, 
from  the  skin,  possibly  in  the  evacuations  from  the  bowels.  It 
is  then  conveyed  through  the  air  or  by  fomites,  and  inhaled  or 
perhaps  swallowed,  so  finding  its  way  into  the  blood  of  fresh 
victims. 

a  Virchow's  Arckiv.     Vol.  XLIIT.,  page  268. 

b  VierteJjahrsschr.  fur  die  med.  Wissensch.     No.  36. 

e  Brit.  Mid.  Journal.  Cf.  Manual  of  Bacteriology.  By  E.  M.  Crookshank. 
Second  Edition,  1887.     Page  214. 

d  Sbornik  lekdrski.  Praze.  Archives  bohemes  de  Medecine.  Vol.  III.,  No.  1. 
Sajous'  Annual  of  the  Universal  M edical  Sciences.     1891.     Vol.1.,  H.-56. 


TYPHUS    FEVER.  245 

2.  The  striking  distance  of  typhus  is  not  great,  provided  only  a 
fresh  air  space  separates  the  sick  from  the  healthy.  In  other 
words,  the  poison  of  typhus  is  most  readily  neutralised  on  coming 
into  contact  with  fresh  air — probably  by  oxidation.  Unlike  the 
contagia  of  smallpox  and  of  scarlet  fever,  the  poison  of  typhus  does 
not  cross  open  spaces. 

3.  Typhus  poison  is  readily  absorbed  by  articles  of  clothing, 
bedding,  furniture,  and  beams  of  wood.  It  may  even  adhere  to 
the  walls  of  badly-aired  buildings.  It  may,  therefore,  be  carried  by 
fomites,  such  as  garments  impregnated  with  it — especially  woollen 
fabrics,  and — as  pointed  out  by  Haller,  of  Vienna — dark- coloured 
rather  than  %fa-coloured  clothing.  It  may  be  mentioned  that 
Stork  found  that  in  dissecting  rooms  dark  clothes  acquired  the 
cadaveric  odour  sooner  than  light  ones,  and  ascertained  by  experi- 
ments that  the  absorption  of  odours  is  regulated  by  the  laws  which 
govern  the  absorption  of  light. 

4.  The  consensus  of  opinion  is  that  the  poison  of  typhus  is  not 
thrown  off  by  the  patient  to  any  great  extent  in  the  earlier  stages 
of  the  fever — probably  not  until  after  the  ninth  day.  The  late 
Dr.  R.  Perry ,a  of  Glasgow,  was  the  first  to  advance  the  opinion 
that  the  period  of  convalescence  is  the  most  infectious  in  typhus, 
and  Murchison's  observations  at  the  London  Fever  Hospital  con- 
firm Dr.  Perry's  at  the  Glasgow  Royal  Infirmary. 

5.  The  experiments  of  Dr.  O.  Motschutkovskyb  show  that 
neither  typhus  nor  enteric  fever  can  be  communicated  to  man  by 
inoculating  the  blood — this  fever  is,  therefore,  not  inoculable. 

6.  One  attack  of  typhus  generally  confers  immunity  from  a 
second,  but  there  are  rare  yet  notable  exceptions — for  example, 
Murchison  himself  suffered  from  two  severe  attacks,  each  attended 
by  the  characteristic  eruption.  An  abortive  attack  ("  typhisation  a 
petite  dose"  Jacquot)  probably  protects  the  system  no  more  than 
an  abortive  attack  of  scarlatina. 

7.  According  to  Haller,  the  contagium  of  typhus  is  lighter  than 

B  Letter  on  Typhus  Fever.    Dubl.  Quart.  Journ.  of  Med.  Science.    Vol.  X.    1836\ 
b  Experiment.  Stud,  iiber  die  Impfbarkeit  des  Kiickfallstyphus.     Centralblatt 
fur  die  med.  Wissenschaft.     1876.     No.  11. 


246  TYPHUS   FEVER. 

atmospherical  air.  His  experiment  was  to  admit  ozone  into  the 
atmosphere  of  a  typhus  ward,  when  it  was  found  to  become  lost 
first  in  the  air  near  the  ceiling.  He  found  that  typhus  spread  to 
the  upper  stories  of  a  hospital  when  it  was  treated  on  the  ground 
floor,  whereas  the  patients  in  the  lower  stories  enjoyed  perfect 
immunity  when  the  typhus  patients  were  treated  on  the  top  landing. 
This  was  so  well  known  at  the  Meath  Hospital  that,  when  I  was  a 
student  there  a  quarter  of  a  century  ago,  the  typhus  cases  were 
treated  in  wards  at  the  top  of  the  General  Hospital.  This  plan, 
of  course,  has  been  long  since  abandoned,  as  the  construction  of 
isolated  Epidemic  Wards  in  the  grounds  of  the  hospital  made  it 
unnecessary  to  treat  infectious  fevers  in  the  main  building. 

The  specific  gravity,  then,  of  typhus  contagium  is  light.  It  is 
a  volatile  poison. 

8.  There  is  strong  presumptive  evidence  that  dry  heat  is  a 
powerful  disinfectant  agent  in  typhus.  In  1831,  W.  Henry a 
made  a  series  of  experiments  of  "  doubtful  propriety  "  (Murchison) 
which  went  to  show  that  articles  of  clothing  impregnated  with 
typhus  poison  are  rendered  innocuous  by  exposure  for  some  hours 
to  a  temperature  of  204°  Fahr. 

9.  There  is  as  yet  no  evidence  that  typhus  is  communicable  to 
the  lower  animals,  or  that  a  disease  identical  with  human  typhus 
prevails  amongst  them. 

While  admitting  that  the  primary  exciting  cause  of  typhus  is  a 
specific  poison,  Murchison  was  of  opinion  that  this  poison  is  not 
only  derived  from  persons  previously  infected  (contagion),  but  also 
may  be  generated  independently.  The  conditions  under  which  he 
supposed  that  the  poison  is  developed  de  novo  are :  overcrowding 
of  squalid  human  beings  and  deficient  ventilation  ;  in  other  words — 
the  poison  is  generated  by  the  concentration  of  the  exhalations 
from  living  beings,  whose  bodies  and  clothing  are  in  a  state  of 
great  filth. 

That  typhus  is  eminently  infectious,  or  "  taking,"  few  if  any  will 
be  found  at  the  present  day  to  deny.  Probably  it  is  at  once  the 
most  infectious  and  the  most  preventable  of  the  fevers.  Murchison 
a  Philosophical  Magazine.     Vols.  X.  &  XI.     1831. 


TYPHUS    FEVER.  247 

sums  up  the  evidence  of  its  contagiousness  by  stating  five  facts  in 
relation  to  this  point.     These  are  the  following  :  — 

1.  When  typhus  commences  in  a  house  or  district,  it  often 
spreads  with  great  rapidity. 

2.  The  prevalence  of  typhus  in  single  houses  or  in  circumscribed 
districts,  is  in  direct  proportion  to  the  degree  of  intercourse  between 
the  healthy  and  the  sick. 

3.  Persons  in  comfortable  circumstances,  and  living  in  localities 
where  the  disease  is  unknown,  are  attacked  on  visiting  infected 
persons  at  a  distance. 

4.  Typhus  is  often  imported  by  infected  persons  into  localities 
previously  free  from  it. 

5.  The  contagious  nature  of  typhus  is  indicated  by  the  success 
attending  the  measures  taken  to  prevent  its  propagation,  more 
especially  the  early  removal  of  the  sick. 

So  far  there  is  no  room  for  controversy,  but  it  is  otherwise 
when  Murchison  advocates  the  doctrine  of  the  spontaneous  or  de 
novo  origin  of  typhus.  In  support  of  this  doctrine  he  appeals  to 
the  arising  of  sporadic  cases  in  the  absence  of  any  great  epidemic, 
and  of  outbreaks  in  public  institutions  and  among  isolated  bodies 
of  men.  As  examples  of  the  alleged  spontaneous  origin  of 
typhus  he  instances  six  historical  "  black  assizes,"  in  which  a 
highly  pestilential  "jail-fever"  broke  out;  various  isolated  out- 
breaks of  "ship-fever"  and  of  "  military  fever " ;  and  Sir  John 
Pringle's  account  of  what  he  called  "hospital  fever."  With 
singular  short-sightedness  for  him,  Murchison  observes  that  down 
to  the  commencement  of  the  present  century  no  doubt  existed  on 
this  matter.  "  All  our  great  physicians  of  the  past — Huxham, 
Pringle,  Cullen,  D.  Monro,  Blane,  Stanger,  Bateman,  &c,  re- 
echoed the  opinion  of  England's  greatest  Lord  Chancellor,  Lord 
Bacon,  and  most  emphatically  declared  that  typhus  often  originated 
de  novo  under  the  circumstances  above  specified."  He  sums  up  the 
opinions  of  these  authorities  in  the  quaint  but  expressive  language 
of  William  Grant,  as  contained  in  his  essay  on  the  "Pestilential 
Fever  of  Sydenham."  According  to  that  author,  "  the  seminium 
of  a  pestilential  fever  "  is  soon  bred  by  overcrowding  and  defective 


248  TYPHUS    FEVER. 

ventilation,  which  "  seminium  once  produced  is  easily  spread 
by  contagion." 

Surely  the  fact  that  the  spontaneous  generation  of  typhus  began 
to  be  questioned  at  the  commencement  of  the  present  century, 
should  have  suggested  to  so  acute  an  observer  as  Murchison  the 
reflection  that  this  shaking  of  a  primeval  faith  was  caused  by  an 
increasing  knowledge  of  the  nature  and  aetiology  of  typhus.  He 
adduces  much  stronger  evidence  in  support  of  his  views  when  he 
quotes  Jacquot,  the  French  medical  historian  of  the  Crimean  War, 
who  wrote a: — "Pas  une  contestation  ne  s'est  elevee  au  sujet  de 
la  cause  du  typhus;  les  faits  sont  clairs  et  parlants ;  le  typhus 
spontane  est  du  aux  miasmes  humains  qui  s'exhalent  au  milieu  de 
l'agglomeration,  de  l'encombrement,  etc.  On  pent  /aire  nattre  le 
typhus  a  volonte,  pour  ainsi  dire." 

In  support  of  this  doctrine,  Murchison  also  quotes  Dr.  Alfred 
Hudson  in  these  words  : — "  While  in  Ireland  the  power  of  ochlesis  b 
to  generate  the  poison  of  typhus  without  the  introduction  of  extra- 
neous infection  is  attested  by  no  less  authority  than  that  of  Dr. 
Hudson."  The  original  words  in  Hudson's  book  are  : — "  In  a  few 
instances  these  [predisposing]  causes  are  found  to  act  with  such 
intensity  as  to  generate  a  fever  poison  without  the  aid  of  any 
exciting  or  extraneous  agency." 

These  views,  curiously  enough,  receive  their  death-blow  from 
Murchison  himself,  when  he  says  : — "  Although  the  nature  of  the 
poison  of  typhus  has  not  yet  been  demonstrated,  it  can  hardly  be 
doubted  but  that  it  consists  of  minute  particles  of  living  matter."  It  is 
true  that  he  adds : — "  This  view,  however,  is  not  incompatible 
with  its  having  an  independent  origin  in  overcrowding."  Why  ? 
Because  "  the  first  effect  of  overcrowding  with  no  ventilation  is  to 
cause  the  respiration  of  an  atmosphere  charged  with  carbonic  acid," 
and  "  the  unrenewed  air  will  become  charged,  not  only  with  car- 
bonic acid,  but  also  with  particles  of  degraded  animal  matter, 
capable,  like  pus  corpuscles,  of  multiplying  in  a  suitable  soil." 
These,  then,  are  the  minute  particles  of  "living  matter"  which 
constitute  the  "  contagium  vivum  "  of  typhus  fever. 

a  Du  Typhus  de  I'Armie  d' Orient.     Paris,  1858. 
1  That  is,  overcrowd  ivy,  from  Gk.  i»x^os>  a  cr"wd. 


TYPHUS   FEVER.  249 

I  venture  to  dissent  from  this  doctrine  of  the  de  novo  or  spon- 
taneous generation  of  typhus  on  the  following  grounds:  — 

1 .  It  is  opposed  to  all  analogy,  so  far  as  the  specific  fevers  are 
concerned.  No  one  suggests  that  smallpox,  or  scarlatina,  or 
relapsing  fever,  arises  de  novo.  Why,  then,  should  it  be  thought 
that  typhus  or  typhoid  does  so  arise  ? 

2.  Notwithstanding  what  Murchison  says  on  the  point,  such  a 
doctrine  denies  the  microbic  origin  of  typhus,  which  I  am  well 
aware  is  not  yet  proved. 

3.  Typhus  did  not  arise  in  certain  extreme  cases  of  over- 
crowding, to  which  Murchison  himself  refers,  such  as  the  "  Black 
Hole  of  Calcutta,"  the  case  of  the  Irish  steamer  Londonderry,  and 
the  tragedy  of  Ujnala.  He  explains  the  failure  of  typhus  to 
appear  in  these  instances  by  saying  there  was  not  sufficient  time 
for  its  development. 

4.  The  doctrine  is  beset  with  difficulties  greater  than  those  it 
is  designed  to  explain.  For  example,  in  an  account  of  an  out- 
break of  typhus  fever  which  took  place  in  Bristol  during  the  year 
1867,  Mr.  D„  Davies,  then  Medical  Inspector  for  that  city, 
expresses  himself  in  no  uncertain  terms  on  the  question  under  con- 
sideration. He  remarks'1: — "I  would  as  soon  believe  in  the  spon- 
taneous generation  of  human  beings  as  I  would  in  the  spontaneous 
generation  of  typhus  fever." 

5.  The  theory  is  unnecessary,  if  we  assume  the  microbic  origin 
of  typhus  and  remember  the  vitality  of  the  resting  spores  of  patho- 
genic micro-organisms  to  which  reference  has  already  been  made. 
[See  page  16]. 

Even  Dr.  Cayley,  the  able  Editor  of  the  posthumous  third  edition 
of  Murchison's  Treatise,  dissents  from  this  doctrine,  for  he  com- 
ments upon  it  thus : — "  Judging,  however,  from  analogy  with 
relapsing  fever  and  other  contagious  diseases,  it  seems  probable 
that  typhus  is  due  to  a  specific  microbe  which  requires  conditions 
of  overcrowding  and  imperfect  ventilation  to  develop  its  virulent 
and  contagious  properties."  b 

a  Medical  Times  and  Gazette.     October  19,  1867. 
b  Loc.cit.     Third  Edition.     1884.     Page  119, 


250  TYPHUS   FEVER. 

"  If  we  reflect,"  says  Mosler,a  of  Greifswald,  "  that  the  contagious 
matter  may  remain  latent  for  years  in  rooms  or  on  furniture,  should 
we  not  then  give  up  the  belief  in  the  spontaneous  origin  of  such  a 
disease?  Unsuspected  ways  in  which  the  poison  has  successively 
passed  from  individual  to  individual,  from  the  cottage  to  the  palace, 
are  being  daily  brought  to  light.  Again,  every  possible  means  of 
communication  in  the  whole  civilised  world  must  be  taken  into 
consideration.  Attention  is  seldom  paid  to  all  the  dangers  of 
transport.  A  carrier  of  the  contagium  rarely  meets  with  an  obstacle 
in  its  passage  from  the  sick  room  to  the  healthy.  Coins  and  bank 
tokens  never  meet  with  the  fate  of  annihilation.  One  cannot  tell 
whether  the  money  previously  belonged  to  one  who  was  healthy  or 
diseased.  As  to  paper  money,  which  is  composed  of  organic 
masses,  there  can  be  no  doubt  but  that  it  might  take  up  infectious 
matter.  Small  coins,  also,  especially  those  of  nickel,  which  lose 
their  smooth  surface  when  long  in  circulation,  become  thickly 
coated  with  particles  of  dirt,  and  impregnated  with  infectious  matter, 
particularly  as  they  often  serve  as  playthings  for  sick  children. 
Having  regard  to  all  the  possible  ways  in  which  transference  of 
the  infection  may  be  effected,  can  we  any  longer  cling  to  the 
doctrine  of  the  spontaneous  origin  of  typhus  ?  " 

"  The  hypothesis  of  a  '  spontaneous  generation '  of  infectious 
diseases,"  wrote  Niemeyer,b  "  in  the  sense  that  their  cause  is  a  new 
agent  induced  by  injurious  influences  is,  of  course,  to  be  rejected, 
for  in  that  case  we  should  be  inferring  a  generatio  cequivoca,  which 
has  been  disproved." 

II.  To  those  circumstances,  which  in  themselves  are  insufficient 
to  generate  the  disease,  but  which  render  the  body  more  liable  or 
susceptible  to  the  influence  of  the  primary  exciting  cause — that  is, 
the  essential  or  specific  poison,  virus,  or  contagium — and  without 
which  the  latter  would  often  prove  inert,  the  term  "  predisposing 
causes  "  is  applied. 

a  Real-Encyclopadie  der  gesammten  ETeilkunde.  Wien  und  Leipzig :  Urban  und 
Schwarzenberg.     Vol.  VII.     Art.,  "  Fleoktypbus." 

b  A  Text-book  of  Practical  Medicine.  London  :  H.  K.  Lewis.  1880.  Revised 
Edition.     Page  615. 


300 


3000 


Diagram  A.,  shows  the  Ages  of  18,138  ccoses  of  Typhus  Fever,   a-dmitted;  uito  the 
JLoTidoTb  Fever  Ho  spilc/t,  with  ike  riwrrvb <er  'of  deaths  HBS  a±>  eaxzfa  cu/e 


TYPHUS    FEVER.  251 

Murchison  discusses  the  following  predisposing  causes  of 
typhus : — 

1.  £ex. — This  does  not  in  itself  predispose  to  this  fever. 
Out  of  18,268  cases  of  typhus  admitted  to  the  London  Fever 
Hospital  during  the  twenty-three  years,  1848-1870,  inclusive, 
8,946  were  males,  and  9,322  were  females.  The  excess  of 
females  was,  thus,  376;  but  this  is  accounted  for  by  the  pre- 
ponderance of  that  sex  in  the  total  population.  Lebert,  the 
writer  of  the  article  on  "Typhus  "  in  von  Ziemssen's  "Cyclopaedia 
of  the  Practice  of  Medicine,"  found  from  accurate  records  of  740 
cases  observed  in  epidemics  at  Breslau  that  55'68  per  cent,  of  the 
patients  were  males,  and  only  44*32  per  cent,  were  females. 

2.  Age. — No  period  of  life  is  exempt  from  typhus,  but  it  is 
for  the  most  part  a  disease  of  adult  age.  Murchison  ascertained 
that  the  mean  age  of  3,456  cases  admitted  into  the  London  Fever 
Hospital  in  the  ten  years,  1848-57,  was  29-33  years.  The 
accompanying  Diagram  (A)  has  been  copied  from  the  third 
edition  of  Murchison's  "Treatise  on  the  Continued  Fevers  of 
Great  Britain,"  with  the  sanction  of  the  Editor,  Dr.  William 
Cayley,  F.R.C.P.,  and  by  the  kind  permission  of  the  Publishers, 
Messrs.  Longmans,  Green,  &  Co.  A  careful  study  of  this  instruc- 
tive diagram  will  show  (1)  the  incidence  of  typhus  in  each 
lustrum  of  life  ;  (2)  the  remarkable  influence  which  age  exercises 
over  the  rate  of  mortality  from  this  fever. 

3.  Season. — During  twenty-three  years,  January  and  March 
were  the  months  in  which  the  number  of  admissions  of  typhus 
patients  to  the  London  Fever  Hospital  reached  a  maximum — the 
minimum  falling  in  September,  August,  and  July.  This  distribu- 
tion was  from  time  to  time  disturbed  by  an  epidemic,  outbreaks  of 
typhus  commencing  and  advancing  irrespective  of  season.  An 
examination  of  the  Registrar-General's  Returns  of  deaths  from 
typhus  in  Dublin,  undertaken  many  years  ago,  led  me  to  the  con- 
clusion that  the  death-rate  from  typhus  attains  its  maximum  in 
January,  and  its  minimum  in  September.  The  reason  for  this 
is  not  far  to  seek.  Typhus  is  often  intimately  related  to  over- 
crowding, and  affections  of  the  respiratory   organs  are  among  its 


252  TYPHUS    FEVER. 

most  frequent  complications.  Hence  we  should  expect  to  meet 
with  it,  especially  in  the  colder  seasons  of  the  year.  Murchison 
points  out  that  typhus  does  not  always  become  more  prevalent  with 
the  commencement  of  cold  weather,  nor  does  it  decline  immediately 
on  the  advent  of  summer.  He  correctly  infers  from  this  that  the 
increase  of  typhus  in  winter  and  spring  is  not  so  much  due  to  the 
direct  effect  of  cold  as  to  the  continued  overcrowding  and  defective 
ventilation  of  the  dwellings  of  the  poor  in  cold  weather. 

4.  Temperature  and  Moisture  in  the  atmosphere  do  not  seem 
to  have  any  marked  predisposing  influence  on  typhus,  notwith- 
standing the  opinion  advanced  by  Dr.  T.  W.  Grimshaw,a  now 
Registrar-General  for  Ireland,  in  1866,  that  a  warm  moist  state 
of  the  atmosphere  seemed  to  favour  an  increase  of  typhus,  whereas 
dryness  with  cold  had  a  contrary  influence.  Murchison  was  unable 
to  trace  any  such  connection,  but  points  out  that  exposure  to  cold 
and  wet,  if  long  continued,  depresses  the  nervous  system  and  so 
favours  the  onset  of  typhus. 

5.  Occupation  dees  not  predispose  to  this  fever  except  so  far  as 
it  involves  actual  exposure  to  the  poison,  as  in  the  case  of  physi- 
cians, medical  students,  nurses,  and  laundresses.  Dr.  Alexander 
Tweedie  considered  that  butchers  were  particularly  exempt  from 
typhus.  There  is  no  reason  why  they  should  be  so,  beyond  the  fact 
pointed  out  by  Murchison,  that  they  usually  have  an  abundant 
supply  of  nourishing  food. 

6.  Idiosyncrasy. — By  using  this  term,  Murchison  wishes  to 
convey  that  some  persons  show  a  complete  natural  immunity 
from  typhus,  whereas  others  have  a  peculiar  aptitude  for  con- 
tracting the  disease,  not  once  but  twice,  as  happened  in  his  own 
case. 

7.  Intemperance  not  only  strongly  predisposes  to  typhus,  but 
greatly  increases  its  danger.  This  has  been  already  pointed  out.b 
Even  a  single  act  of  intoxication  may  predispose  to  this  fever. 
Murchison  met  with  several   instances  of  persons  exposed  to  the 

a  "  On  Atmospheric  Conditions  influencing  the  Prevalence  of  Typhus."    DM. 
Quar.  Journ.  of  Med,  Science,  May,  1866. 
•    b  See  Chapter  IV.,  pages  39  and  42. 


TYPHUS    FEVEK.  253 

poison  for  months  who  were  not  attacked  until  immediately  after 
a  debauch. 

8.  Bodily  fatigue. — Whatever  lowers  vitality  and  exhausts  and 
debilitates  the  body,  like  fatigue,  want  of  sleep,  and  pain,  predis- 
poses to  typhus. 

9.  Mental  fatigue  and  depressing  emotions,  such  as  sorrow, 
fear,  disappointment,  and  anxiety,  have  a  like  effect.  Cheerfulness 
and  confidence,  on  the  other  hand,  aid  an  individual  to  resist  the 
fever  poison. 

10.  Previous  illnesses  predispose  to  typhus.  A  "  feverish  cold  " 
is  sometimes  said  "  to  develop  into  typhus."  This  is  not  what 
really  happens  ;  but  the  catarrh  increases  the  susceptibility  of  the 
individual  to  the  fever  poison.  In  hospital  practice,  convalescents 
from  other  diseases  are  often  attacked  by  typhus  if  the  virus  is 
about.  Simple  fever  and  scurvy  strongly  predispose.  Yon  Hilden- 
brand's  view,  put  forward  in  1811,  that  typhus  rarely  attacks 
phthisical  subjects,  does  not  rest  on  sure  ground. 

11.  Eecent  residence  in  an  infected  district  greatly  increases 
the  risk  run  by  an  individual  exposed  to  typhus.  Persons  continu- 
ously so  exposed  appear  to  become  acclimatised  in  a  greater  or 
less  degree.  We  can  imagine  that  "  typhisation  a  petite  dose  "  (to 
use  Jacquot's  eloquent  phrase),  repeated  again  and  again,  may  in 
time  exhaust  the  soil  for  typhus  as  effectually  as  one  thorough  and 
unequivocal  attack  of  the  fever. 

12.  Overcrowding  of  human  beings,  with  deficient  ventila- 
tion, is  one  of  the  most  powerful  predisponents  of  typhus.  To 
this  fact  testimony  is  borne  by  all  the  historians  of  epidemics  of 
the  disease. 

13.  Lastly,  destitution  and  deficient  alimentation  are  abso- 
lutely the  most  powerful  predisposing  causes  of  typhus.  It  is 
essentially  a  poor  man's  disease.  Famine  and  pestilence  "hunt  in 
couples  "  in  this  instance,  as  in  many  others  also. 

In  conclusion,  we  may  sum  up  the  facts  relating  to  the  aetiology 
of  Typhus,  after  Murchison,  in  the  following  sentences : — 

1.  Typhus  is  due  to  a  specific  poison,  the  entrance  of  which  into 
the  system  is  the  prime  exciting  cause  of  the  fever. 


254  TYPHUS   FEVER. 

2.  This  poison  is  communicated  from  the  sick  to  the  healthy 
through  the  atmosphere,  or  by  fomites ;  but  is  rendered  inert  by 
free  ventilation. 

3.  The  great  predisposing  causes  of  typhus  are,  in  the  order  of 
their  aetiological  importance — destitution  and  defective  nutrition, 
overcrowding,  bad  ventilation. 

4.  In  the  presence  of  these  factors,  a  small  and  hitherto  inert 
dose  of  the  fever  poison  may  kindle  a  serious  outbreak  of  typhus  in 
such  a  way  as  to  suggest  that  the  fever  has  arisen  spontaneously 
or  de  novo. 


255 


CHAPTER  XXVII. 
Clinical  Description  or  Typhus  Fever. 

Stages  op  Typhus:  (1.)  Incubation— about  twelve  days,  or  less.  (2.)  Inva- 
sion— earliest  symptoms  referable  to  the  Nervous  System.  (3.)  Nervous  Excite- 
ment (Eablier  Eruptive  Stage).  Objective  Symptoms:  typhus  rash,  maculse, 
subcuticular  mottling,  "Mulberry  Rash  "  (Jenner).  Delirium:  ferox,  tremens, 
typbomania  (Galen).  (4.)  Nervous  Prostration  (Later  Eruptive  Stage) — 
characterised  by  ataxia  and  adynamia.  Petechias — the  "  Typhoid  State  " — its 
symptoms.     (5.)   Defervescence  or  Crisis.     Modes  of   Crisis  :  sleep,  slight 

diarrhoea,  diuresis,  perspiration.  (6.)  Convalescence. — Duration  of  Typhus. 

Blasting  Typhus,  or  T.  siderans. — Typhus  kvissimus. — Relapses. — Temperature 
in  Typhus. — Hyperpyrexia. 

We  may  most  fitly  consider  the  course  of  typhus  fever  as,  for  con- 
venience, divided  into  certain  stages — those  specified  by  Murchison 
being  the  most  convenient  of  all.  They  are  the  stages  respectively 
of— (1.)  Incubation;  (2.)  Invasion;  (3.)  Nervous  Excitement, 
Earlier  Eruptive  Stage ;  (4.)  Typhoid  State,  Later  Eruptive 
Stage ;  (5.)  Defervescence,  or  Crisis ;  (6)  Convalescence,  Nervous 
Prostration.  "The  duration  of  these  stages,"  says  Murchison.3, 
"  varies  in  different  cases — some  may  be  shortened  or  altogether 
absent,  and  occasionally  it  may  be  difficult  to  say  when  one  stage 
ends  and  another  begins." 

I.  Stage  of  Incubation. — In  typhus  fever  there  seems  to  be  no 
fixed  duration  for  this  stage.  In  a  paper  published  in  the  second 
volume  of  the  "St.  Thomas's  Hospital  Reports"  (1871),  in  which 
Dr.  Murchison  collected  31  cases  where  he  had  been  able  to 
determine  the  period  of  incubation,  that  author  arrived  at  the 
following  conclusions : — 

1.  The  period  of  incubation  of  typhus  varies  in  duration  in 
different  cases. 

2.  In  a  large  proportion  of  cases  it  is  about  twelve  days. 

3.  In  exceptional  cases  it  is  longer  than  twelve  days ;  but  it 
rarely,  if  ever,  exceeds  three  weeks. 

*Loc.  cit.     Third  Edition.     Page  179. 


256  TYPHUS   FEVER. 

4.  In  many  cases  (one-third  or  more)  it  is  less  than  twelve 
days,  and  occasionally  there  is  scarcely  any  latent  period,  the 
symptoms  commencing  almost  at  the  instant  of  exposure  to  the 
poison.  It  would  seem  that  the  poison  of  typhus  may  be  so  concen- 
trated, or  the  system  may  be  so  susceptible  to  its  action,  that  its 
effect  may  be  almost  instantaneous.  Generally,  the  patients  are 
conscious  of  the  moment  when  the  fever  poison  enters  the  system. 
In  my  own  person,  I  have  often  suffered  from  a  "  typhus  head- 
ache "  almost  immediately  after  exposure  to  the  poison  of  this 
disease. 

In  one  melancholy  and  tragic  instance  I  had  an  opportunity  of 
estimating  the  duration  of  the  stage  of  incubation  in  typhus  with 
a  certain  degree  of  accuracy.  On  the  night  of  Wednesday, 
December  28,  1881,  my  friend  and  colleague,  Dr.  Reuben  J. 
Harvey,  Physician  to  Cork-street  Fever  Hospital,  died  on  the 
tenth  day  of  petechial  typhus.  At  the  beginning  of  December 
Dr.  Harvey,  then  thirty -six  years  of  age,  seemed  to  be  in  the  enjoy- 
ment of  perfect  health.  He  attended  a  meeting  of  the  Physiological 
Society  in  London  on  the  evening  of  the  8th,  and  returned  to 
Dublin  on  the  9th,  travelling  all  night.  On  Saturday,  the  10th,  he 
attended  the  wards  of  Cork-street  Fever  Hospital,  where  there  was 
very  little  typhus  at  the  time.  On  the  morning  of  the  11th,  how- 
ever, he  examined  a  lad  who  had  been  admitted  the  previous 
evening,  on  the  eighth  day  of  typhus.  This  patient  he  continued 
to  attend  daily,  until  his  own  illness  had  lasted  at  least  twenty-four 
hours. 

On  December  19,  Dr.  Harvey  did  not  feel  well;  next  day  he 
suffered  from  severe  headache.  On  the  22nd,  he  was  too  ill  to 
leave  his  bed.  Early  on  Friday,  the  23rd,  macula?  appeared  (4th- 
5th  day),  and  ultimately  there  was  a  profuse  rash,  which  very 
soon  became  petechial.  Almost  incessant  wakefulness  was  among 
the  first  dangerous  symptoms  ;  but  at  a  very  early  stage  the  heart 
became  weak  and  its  action  rapid,  and  the  respirations  ran  up  to 
60  in  the  minute  without  any  pulmonary  complication  to  account 
for  this  untoward  symptom.  The  downward  progress  was  swift, 
and  the  end  came  on  the  evening  of  the  tenth  day. 


TYPHUS    FEVER.  257 

In  this  case,  so  pathetic  in  its  sadness,  and  which  lost  to  Cork- 
street  Fever  Hospital  the  services  of  a  most  able,  learned,  and  con- 
scientious physician,  the  period  of  incubation  could  not  have 
exceeded  10  days,  and  was,  most  probably,  8  or  9  days  in  length. 

Niemeyer,  in  his  "  Text  Book  of  Clinical  Medicine,"  gives  two 
remarkable  examples  of  the  contagiousness  of  typhus,  which  are 
also  of  value  as  contributions  to  the  evidence  as  to  the  duration  of 
its  period  of  incubation.  In  the  year  1854  two  typhus  patients 
were  received  into  the  Magdeburg  Hospital  from  the  prison,  which 
was  much  crowded.  For  months  previous  there  had  been  only  a 
few  cases  of  typhoid  fever  and  not  a  single  case  of  typhus  in  his 
wards.  Eight  days  alter  the  reception  of  these  patients,  two 
others  who  had  lain  beside  them  were  attacked  by  the  same 
disease.  One  of  the  latter  patients  had  been  admitted  for  inter- 
mittent fever,  the  other  for  epilepsy.  Again,  in  March,  1855,  a 
tradesman  from  Heiligen.stadt  was  attacked  with  typhus  while 
away  from  home.  He  was  received  into  Niemeyer's  ward,  in  which 
no  typhus  had  been  treated  for  almost  a  year.  Eight  days  after 
the  reception  of  this  patient,  a  blacksmith's  apprentice  and  a 
mechanic,  lying  next  to  him,  were  attacked  by  the  fever. 

In  Murchison's  second  attack  of  typhus,  the  incubation  staa-e 
lasted  exactly  5  days.  Mr.  Da  vies, a  whom  I  have  already  quoted  on 
the  subject  of  the  spontaneous  generation  of  typhus,  states  in  the 
same  paper  that  in  1867  four  Norwegian  sailors,  on  the  ni°-ht  of  the 
arrival  of  their  ship  in  Bristol  from  Onega,  visited  some  typhus  fever 
nests,  and  all  four  sickened  with  typhus  eight  days  afterwards. 

II.  Stage  of  Invasion. — One  or  two  days  of  slight  indisposition, 
shown  by  lassitude,  vertigo,  slight  headache,  and  loss  of  appetite 
may  precede  the  true  onset  of  typhus,  which  is  sudden.  The 
symptoms,  as  usual  in  specific  fevers,  are  referable  to  the  nervous 
system ;  they  are — chilliness  or  slight  rigors,  languor,  frontal  head- 
ache, pains  in  the  back  and  limbs,  especially  the  thighs.  The  chilli- 
ness comes  and  goes,  and  complete  loss  of  appetite,  with  constipation 
and  sometimes  nausea  (but  no  vomiting),  follows.  The  tongue  is  laro-e 
pale,  and  coated— first  with  a  white,  afterwards  with  a  yellowish 
"Medical  Times  and  Gazette.     Oct.  19,  1867.     Page  428. 

S 


258  TYPHUS    FEVER. 

brown  fur.  The  urine  is  scanty,  high-coloured,  and  of  considerable 
density — 1025-1030.  The  pulse  commonly  exceeds  100  and  is 
compressible,  although  rarely  it  is  below  the  normal  rate.  The 
breathing-rate  is  accelerated  in  proportion.  The  face  is  flushed  and 
dusky.  The  eyelids  swell  along  their  edges,  the  eyes  water,  and  the 
conjunctivae  are  injected.  The  expression  at  first  betokens  languor 
and  weariness,  but  soon  becomes  dull,  heavy,  and  listless.  Giddi- 
ness, noises  in  the  ears  {tinnitus  aurium),  and  sleeplessness  are  commonly 
present.  If  sleep  occurs,  it  is  haunted  by  dreams,  the  patient  talks, 
and  his  mind  wanders  in  his  sleep.  A  sense  of  complete  exhaustion 
quickly  overwhelms  the  sufferer,  so  that  by  the  third  day  he  is  fain 
to  take  to  his  bed. 

III.  Stage  of  Nervous  Excitement  (Eruptive  Stage.)— This 
commonly  extends  from  the  appearance  of  the  rash  until  the  com- 
mencement of  somnolence  or  stupor.  Its  leading  features  are 
restlessnes,  wakefulness,  and  delirium.  During  this  stage  headache 
gives  place  to  raving,  and  the  tongue  grows  dry  and  brown,  while 
collections  of  sordes  gather  on  the  teeth  and  gums. 

About  the  fourth  or  fifth  day  the  first  stage  of  the  typhus 
eruption  may  be  observed.  It  is  a  rash,  or  exanthem,  often  closely 
resembling  the  rash  of  measles,  and,  in  consequence,  called  "  mor- 
billiform,'' "rubeoloid,"  or  "measly."  It  consists  of  spots,  or 
"  maculae,"  of  very  irregular  size  and  outline,  and  of  a  dirty  pink 
or  florid  colour,  which  appear  first  near  the  axillae  and  on  the  wrists, 
then  on  the  sides  of  the  abdomen,  afterwards  on  the  chest,  back, 
shoulders,  thighs,  and  arms.  They  are  rarely  seen  on  the  face  or 
neck,  for  two  reasons — first,  these  parts  are  very  vascular,  and  the 
general  hyperemia  or  congestion  of  the  fever  conceals  the  rash ; 
secondly,  the  rash  develops  less  quickly  and  less  thoroughly  in  parts 
freely  exposed  to  the  air.  When  they  first  appear,  and  also  when 
they  are  few  in  number,  as  in  the  milder  cases,  they  are  slightly 
elevated  and  deleble  on  pressure,  like  the  velvety  papules  of  measles. 
They  have,  however,  no  defined  margin,  but  merge  insensibly  into 
the  colour  of  the  surrounding  skin.  Along  with  these  superficial 
spots  there  is  a  characteristic  marbling  or  mottling  of  the  skin, 
caused  by  the  presence  beneath   the  cuticle  of  another  crop  of 


TYPHUS    FEVER.  259 

maculae.  Hence  the  term  "subcuticular  mottling."  The  spots 
and  mottling  together  constitute  an  eruption  to  which  Sir  William 
Jenner  first  gave  the  name  of  the  "mulberry  rash"  of  typhus. 

Towards  the  close  of  the  first  week,  on  the  5th  day  usually,  the 
headache  gives  place  to  delirium,  which  is  sometimes  acute  and 
noisy,  like  mania  (delirium  ferox) ;  sometimes  more  like  that  of 
excessive  alcoholism,  being  accompanied  by  muscular  agitation  and 
trembling  (delirium  tremens) ;  and  sometimes'of  a  low  muttering 
kind  (the  typhomania  of  Galen.)  The  nervous  excitement  is 
most  marked  towards  evening  and  at  night,  prostration  taking 
its  place  in  the  morning. 

IV.  Stage  of  Nervous  Prostration— the  Typhoid,  Putrid,  or 
Malignant  Stage  (Later  Eruptive  Stage.) — This  is  characterised 
by  extreme  nervous  prostration  (ataxia),  and  muscular  and  cardiac 
weakness  (adynamia),  defective  cerebration,  low  muttering  de- 
lirium, stupor,  and  unconsciousness  deepening  into  coma.  The 
patient  lies  on  his  back  (prostrate  dorsal  decubitus),  moaning  or  talking 
to  himself  incoherently,  with  a  tendency  to  sink  down  in  the  bed. 
He  is  utterly  indifferent  to  what  goes  on  around  him,  looks  stupid 
and  unconscious,  with  inj ected  ferret-like  eyes,  contracted  pupils  (the 
"pin-hole  pupil"  of  Graves),  teeth  covered  with  sordes,  and  dry  brown- 
crusted  tongue.  Deafness  is  not  infrequent.  Other  symptoms  are  : 
tremors,  subsultus  tendinum,  spasmodic  twitchings  of  the  face,  and  even 
well-marked  choreic  convulsions,  or  more  commonly  picking  or fumbling 
with  the  bedclothes — the  so-called  Floccitatioa  or  Carphology.b 
Obstinate  hiccough  often  accompanies  these  various  involuntary 
movements,  and  is  a  very  grave  sign.  Not  uncommonly,  also, 
involuntary  evacuations  take  place  from  paresis  of  the  sphincters  of 
the  rectum  and  bladder.  The  pulse  is  rapid,  small,  and  soft 
(112  to  140),  and  the  respirations  are  shallow,  frequent,  blowing, 
and  noisy — the  "  cerebral  breathing  "  of  Sir  Dominic  Corrigan. 

Simultaneously  with  the  supervention  of  the  foregoing  unfavour- 
able symptoms,  the  eruption  changes   in   character,    becoming 

a  Lat.  floccvs,  a  lock  or  flock  of  wool. 

b  Greek  Kapcpos,  a  dry  .-talk  ;  Xeyus,  I  gather,  pick  up,  and  lay  in  order.  Galen 
(A.D.  1*63)  uses  the  word  napcpoAoyia,  a  gathering  oj  chips,  dec. 


260  TYPHUS    FEVER. 

darker  in  colour  and  quite  indelible  on  pressure.  The  spots  are 
no  longer  elevated,  and  in  the  centre  of  many  of  them  dark  purple 
or  bluish  points  appear — the  true  petechise,  which  Murchison 
defines  as  consisting  of  an  infiltration  of  dissolved  haematin  into  the 
tissue  of  the  cutis.  The  peculiarity  of  typhus,  so  far  as  the  rash 
is  concerned,  consists  in  an  eruption  which,  in  its  earlier  stage,  is  a 
true  exanthem  due  to  hyperemia  of  the  cutaneous  capillaries,  while 
in  its  later  stages  an  escape  of  blood-pigment  into  the  cutis  is  sub- 
stituted for  this  hypersemia.  The  rashes  of  other  diseases  may  be 
accompanied  with  the  development  of  petechia?,  but  are  not,  like  the 
macular  rash  of  typhus,  converted  into  petechia. 

The  earlier  and  more  marked  the  "  typhoid  state "  just 
described  is,  the  more  severe  is  the  case.  The  older  writers  spoke 
of  it  as  the  putrid  or  malignant  state.  It  is  by  no  means  peculiar 
to  typhus.  We  have  seen  that  it  occurs  in  smallpox  and  scarlatina, 
and,  indeed,  any  idiopathic  fever,  or  blood-poisoning,  or  local  in- 
flammation, may  pass  into  this  state. 

In  such  a  dire  strait  the  patient  may  lie  for  many  hours, 
or  several  days,  life  trembling  in  the  balance,  until  the  stupor 
passes  into  profound  and  fatal  coma,  or  sudden  engorgement  of  the 
lungs  with  asphyxia  supervenes,  or  the  heart  fails,  with  coldness 
and  lividity  of  surface  and  profuse  sweating — death  ensuing  from 
syncope  and  coma  combined. 

V.  Stage  of  Defervescence  or  Crisis. — Happily,  such  is  not 
always,  or  even  frequently,  the  end  of  an  attack  of  typhus.  More 
usually,  on  or  about  the  fourteenth  day  there  is  a  more  or  less 
sudden  improvement.  The  patient  falls  into  a  quiet  and  prolonged 
sleep,  from  which  he  awakes  at  first,  it  may  be,  bewildered  and 
confused ;  but  he  quickly  recognises  those  around  him,  and  for  the 
first  time  is  conscious  of  his  profound  weakness.  Pulse  and 
temperature  fall,  the  tongue  becomes  moist  and  begins  to  clean, 
slight  perspiration  sets  in,  or  the  bowels  are  relaxed,  or  the  urine 
becomes  abundant  and  deposits  lithates  (urates)  in  abundance.  In 
few  acute  diseases  is  crisis  so  marked  as  in  typhus.  In  1810,  J.  von 
Hildenbrand  a  stated  that  the  disease  abated  "  after  a  very  rapid 
a  Ueber  den  ansteckenden  Typhus.     Wien.     1810. 


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TYPHUS    FEVKR.  261 

fashion."  In  1840  Dr.  Alexander  P.  Stewart*  said  that  to  the 
turn  in  typhus  we  might  almost  apply  the  Scripture  phrase :  "  At 
such  an  hour  the  fever  left  him."  "  La  fievre,"  said  Jacquot.b 
"  tombe  souvent  avec  une  rapidite  etonnante."  Lastly,  Barrallier  c 
observed  :  "  Cette  periode  (de  remission)  survient  presque  brusque- 
ment." 

The  final  defervescence,  as  marked  by  the  thermometer  is,  to  use 
Wunderlich's  expressive  phrase,  usually  "  precipitous."*1 

VI.  Stage  of  Convalescence. — Once  the  temperature  falls,  resto- 
ration to  health  goes  on  apace.  The  tongue  becomes  clean  and  moist, 
the  appetite  is  ravenous  (boulimia)e  and  the  bodily  powers  improve 
day  by  day,  so  that  in  three  or  four  weeks  health  and  strength  are, 
in  uncomplicated  cases,  fully  restored.  Typhus  but  rarely  lays  the 
foundation  of  any  permanent  organic  disease. 

Duration  of  Typhus. — Murchison  carefully  examined  500  un- 
complicated cases  which  recovered,  and  100  fatal  cases,  with  the 
following  results  : — The  mean  duration  of  the  500  cases  was  13'43 
days.  In  nearly  one-half  (242)  the  cases,  convalescence  commenced 
on  the  thirteenth  or  fourteenth  day,  and  in  384  cases,  or  in  more 
than  three-fourths,  on  the  thirteenth  to  the  sixteenth  day  inclusive. 
The  mean  duration  of  the  100  fatal  cases  was  14*6  days,  but 
when  life  was  prolonged  beyond  twenty  days,  the  fatal  result  was 
due  to  some  complication. 

According  to  Wunderlich,f  "  defervescence  most  commonly  occurs 
between  the  thirteenth  and  seventeenth  days,  less  frequently  between 
the  twelfth  and  thirteenth,  and  still  more  seldom  at  an  earlier 
date." 

Dr.  T.  J.  Maclagan  B  investigated  581  uncomplicated  cases  which 
recovered  in  the  Dundee  Royal  Infirmary,  and  found  their  mean 

a  Edin.  Med.  and  Surg.  Journal,  October,  1840. 
b  Du  Typhus  de  I'Armee  d' Orient.     Paris.     1858.     Page  168. 
c  Du  Typhus  epidemique  a  Toulon.     Paris.     1861.     Page  72. 
d  Medical  Thermometry.     New  Syd.  Soc.     1871. 

e  Gk.  fSovXifiio,  ravenous  hunger  ;  from  $ov-,  used  in  composition  to  denote 
something  huge  and  monstrous  (/3ovs,  an  ox),  and  Aifj.6s,  hunger. 
f  Medical  Thermometry.     New  Syd.  Soc.     1871.     Page  330. 
g  Edin.  Med.  Journal,  August,  1867. 


262  TYPHUS    FEVER. 

duration  to  be  13-39  days — a  value  which  is  practically  identical 
with  Murchison's  estimate. 

Leberta  arranges  the  times  of  occurrence  of  the  "  critical  abate- 
ment "  of  the  fever  of  typhus  in  percentages  as  follows  : 
From  6th  to  8th  day  =        12*3  per  cent.\ 

„     10th  to  12th  day      =       41-9       „         V  =  71-4  per  cent. 
„     13th  to  14th  day      =       29-2       „         ) 

On  the  fifteenth  day  =         8-2       „        1 

}•  =  16'6  per  cent. 
After-      „         „  =         8-4  j  F 

Although  the  duration  of  typhus  is  thus  about  14  days,  this  fever 
may  run  a  much  shorter  course.  This  happens,  on  the  one  hand, 
in  malignant  cases,  which  may  terminate  fatally  on  the  second  or 
third  day,  or  in  a  few  hours.  To  such  cases  the  name  of  Blasting 
Typhus  or  Typhus  Siderans  has  been  given.  This  terrible  form 
of  the  disease  is  apt  to  prevail  in  times  of  war  and  destitution.  In 
ordinary  times,  however,  cases  of  short  duration  are  not  uncommon, 
and  are  usually  mild.  Murchison  gives  the  details  of  cases  with 
eruption  which  terminated  on  the  tenth,  or  even  as  early  as  the 
eighth  day.  In  the  Dublin  Journal  of  Medical  Science  for  July, 
1870,  1  published  a  series  of  cases  of  typhus  fever  of  short  dura- 
tion, all  of  which  terminated  favourably.  The  first  case  was  that 
of  Mary  D.,  a  dairymaid,  aged  twenty-seven,  who  took  ill  on 
Christmas  Eve,  1875.  She  was  admitted  to  the  Meath  Hospital 
on  December  29  (sixth  day),  when  her  skin  was  dusky,  and 
macula?  were  abundant  on  her  back  and  chest.  The  lips  were 
covered  with  sordes.  Her  tongue  was  brown  at  the  edges,  red 
and  dry  in  the  centre  and  at  the  tip.  There  had  been  four  motions 
in  the  preceding  14  hours.  P.  119,  Resp.  27,  Temp.  103'4°. 
Next  day  an  intense  fever  odour  was  observed,  the  skin  was  still 
dusky  and  maculae  were  well  marked.  Defervescence  commenced 
on  this  (the  seventh)  day,  the  pulse  falling  from  116  in  the  morning 
to  99  in  the  evening,  the  respirations  from  40  to  35,  and  the  tem- 
perature from  103-6°  to  103*3°.  By  January  3  (eleventh  day) 
she  was  completely  fever-free— P.  70,  Resp.  20,  Temp.  97-8°. 
The  pulse  intermitted  about  twice  a  minute.     The  weak  state  of 

d  Von  Ziemssen's  Cyclopaedia  of  the  Practice  of  Medicine.     Art.  "  Typhus." 


Plate   VI. 

CHARTS  OF  TEMPERATURE  RANGES  IN  TYPHUS  FEVER 
OF  SHORT  DURATION. 


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TYPHUS    FEVER.  2()3 

the  heart  required  tonics  and  some  stimulants.  The  temperature 
charts  of  this  case  (Fig.  1)  and  of  three  others  which  were 
somewhat  similar  are  reproduced  in  Plate  VI. 

Traube, a  of  Berlin,  in  1853,  revived  Galen's  doctrine  of  critical 
days,  according  to  which  the  fever  should  terminate  on  one  of  the 
odd  days,  and  not  on  the  intervening  even  days.  Murchison's 
observations  do  not  support  this  doctrine  in  reference  to  typhus ; 
but  both  this  fever  and  typhoid  or  enteric  fever  tend  to  terminate 
at  or  near  the  close  of  a  weekly  period. 

Relapses  are  extremely  rare  in  typhus.  Neither  Sir  William 
Jenner,  nor  A.  P.  Stewart,  nor  Murchison,  has  ever  seen  a  case  of 
true  relapse.  Out  of  18,268  cases  of  typhus  reported  at  the  London 
Fever  Hospital  during  23  years,  only  one  example  of  a  true 
relapse  was  observed  (by  Dr.  Buchanan),  although  in  several 
instances  a  genuine  has  been  preceded  by  an  abortive  attack. 
Buchanan's  case  was  that  of  a  nurse  in  the  hospital,  aged  forty- 
two,  who  passed  through  an  undoubted  typhus  fever,  lasting  two 
Weeks.  After  a  week's  interval,  a  relapse  took  place,  with  a  recur- 
rence of  eruption,  lasting  upwards  of  a  fortnight.  A  very  similar 
case  is  recorded  by  W.  Ebstein,b  of  Breslau,  where  there  was  an 
interval  of  25  days  between  the  two  attacks. 

Temperature. — The  facts  to  be  fixed  in  the  memory  relative  to 
the  behaviour  of  the  temperature  in  typhus  are  the  following: — 

1.  A  sudden  rise  of  the  thermometer  takes  place  at  the  outset, 
culminating  in  a  fastigium  which  is  generally  reached  on  the 
evening  of  the  fourth  day,  or  earlier,  but  may  be  postponed  to  the 
seventh  day,  or  later.  In  this  fastigium  the  thermometer  may 
mark  105°,  or  upwards,  or  it  may  not  exceed  103°. 

2.  A  more  or  less  pronounced  remission  of  fever  or  pseudo- 
crisis,  occurs  at  some  time  between  the  seventh  and  tenth  days, 
except  in  severe  cases.  In  mild  cases,  this  fall  of  temperature  at 
the  beginning  of  the  second  week  may  prove  complete  and  final — 
a  true  crisis  cutting  the  fever  short,  as  in  the  cases  of  short  dura- 
tion already  referred  to.     On  the  other  hand,   in  grave  cases,  a 

a  Uebcr  Krisen  und  kritische  Tage.     Berlin.     1852. 
b  Die  Recidive  des  Typhus,     Breslau.     18b9. 


264  TYPHUS   FEVER. 

gradually  rising  temperature  at  this  very  period  may  culminate  in 
a  fatal  hyperpyrexia.     Of  this  I  will  presently  quote  an  example. 

3.  A  renewed  rise  of  temperature  in  the  second  week  culminates 
about  the  eleventh  day  in  a  second  fastigium,  which  in  favourable 
cases  does  not  attain  the  height  of  the  initial  fastigium  of  the  first 
week.  This  second  increase  of  fever  may  be  absent,  the  tempera- 
ture gradually  falling  during  the  second  week,  until  about  the 
fourteenth  day,  when   it  rapidly  sinks  to  or  below  normal. 

4.  Defervescence  is  sudden  in  a  majority  of  cases.  Preceded 
very  often  by  a  final  evening  exacerbation  on  the  12th  or  13th 
day — which  Wunderlich  calls  a  "  critical  perturbation  " — defer- 
vescence is  often  "  precipitous,"  the  temperature  falling  3°  to  5°  F. 
or  more  in  a  single  night,  then  rising  some  2°  in  the  evening,  and 
finally  reaching  the  normal  point  for  the  first  time  next  morning. 
Such  is  the  crisis  of  typhus.  It  is,  in  fact,  very  like  the  critical 
fall  of  temperature  in  both  measles  and  acute  pneumonia  (pneumonic 
fever),  except  that  it  occurs  at  the  end  of  the  second  week  of  the 
fever  instead  of  at  the  end  of  the  first  week,  as  in  the  two  diseases 
named. 

In  severe  cases,  with  cerebral  symptoms  (ataxic  typhus),  tem- 
perature ranges  high  all  through  the  first  week,  there  is  no  remission 
about  the  seventh  day,  and,  worst  of  all,  the  thermometer  continues 
to  rise  in  the  second  week.  This  last  occurrence  often  points  to 
the  advent  of  some  complication  which  may  postpone  defervescence 
indefinitely,  or  it  may  usher  in  excessive  fever  or  hyperpyrexia  as 
already  mentioned. 

On  the  other  hand,  in  adynamic  cases,  with  heart  failure  and 
pulmonary  obstruction,  the  range  of  temperature  may  be  moderate — 
not  exceeding  103°,  or  irregular,  with  spiking,  or  the  fever  may  be 
continuous  with  absence  of  morning  remissions,  or  a  fall  of 
temperature  may  be  observed  with  a  rise  of  pulse-rate,  without  any 
improvement  in  the  general  symptoms.  In  his  "Lectures  on  Fever,"  a 
Dr.  William  Stokes  quotes  an  old  and  well-founded  opinion  that  all 
anomalous  circumstances  in  fever  are  to  be  feared.  The  aphorism 
runs:  "Pulsus,  vultus,  et  urina  bona;  oeger  moritur."  And  it  is 
a  London  :  Longmans,  Green,  &  Co.     1874.     Page  361. 


TYPHUS    FEVER.  265 

true.  Fatal  cases  of  typhus  are  generally  preceded  by  high 
temperature  from  the  very  beginning,  yet  even  in  such  cases  it  is 
not  so  much  the  intensity  as  the  continuance  of  the  fever  which 
determines  the  mortal  result.  Just  before  death  and  in  the  death 
agony,  both  Wunderlich  and  Murchison  describe  a  rise  of  tempera- 
ture as  a  very  constant  phenomenon.  According  to  the  former 
authority,  the  temperature  is  seldom  as  low  as  104°  during  the 
agony,  more  usually  it  ranges  between  105-8°  and  107-6°  F.,  and 
once  it  reached  109*4°  F. 

In  the  Dublin  Journal  of  Medical  Science  for  February,  1878,  I 
published  a  case  of  typhus  with  hyperpyrexia,  in  which  the 
exceptionally  high  reading  of  109-1°  was  recorded  during  the  death- 
agony  of  the  patient,  a  woman,  aged  thirty-eight,  who  succumbed 
on  the  19th  day  of  a  typhus  fever  of  the  nervous  or  ataxic  variety. 

The  following  is  a  brief  history  of  the  case : — 

Margaret  T.,  aged  thirty-eight  years,  married  to  a  shoemaker, 
and  residing  in  Cuffe-street,  Dublin,  was  admitted  to  the  Meath 
Hospital  on  the  afternoon  of  Wednesday,  September  12th,  1877. 
It  is  worth  noting  that  a  young  man  from  the  same  house  was 
under  treatment  for  severe  typhus  in  Cork-street  Fever  Hospital 
from  July  18th  to  September  8th.  There  was  no  special  medical 
history  previously  to  her  present  illness,  which  commenced  on 
Tuesday,  September  4th,  1877,  with  a  shivering  fit,  followed  by- 
chilliness  so  great  as  to  oblige  her  to  hang  over  the  fire  the  greater 
part  of  the  day.  She  also  suffered  from  pains  in  the  limbs.  She 
fought  against  her  illness  until  the  following  Friday  (4th  day),  when 
she  took  to  bed,  as  she  was  getting  much  worse.  On  Saturday,  severe 
pain  in  the  small  of  the  back,  and,  next  day,  vomiting  of  "  watery 
stuff  "  were  superadded  to  obstinate  constipation,  which  was  an 
early  symptom.  From  the  outset  also  she  was  very  sleepless.  She 
did  not  come  into  hospital  until  the  afternoon  of  the  ninth  day. 
In  the  evening  her  pulse  was  120,  her  respirations  were  28  per 
minute,  and  the  axillary  temperature  was  104-9°. 

Next  morning  her  face  presented  a  dusky,  congested  appearance  ; 
the  eyes  were  heavy,  and  the  conjunctivae  deeply  suffused ;  her 
tongue  was  heavily  furred,  but  moist ;  both  it  and  the  lips  were 


206  TYPHUS    FEVER. 

exceedingly  tremulous.  There  was  a  marked  "  nervousness  "  of 
manner.  A  profuse  mulberry  eruption  covered  nearly  all  parts  of 
the  body — the  original  maculae  had  become  true  petechias,  which 
were  unusually  distinct  and  dark  in  colour.  Her  pulse  was  124, 
not  strong;  respirations,  24;  temperature,  104*3°  (at  10  a.m.). 
The  heart's  action  was  rapid  and  weak,  but  both  sounds  were 
audible,  and  the  impulse  could  be  felt  in  the  normal  situation. 

Treatment. — It  was  decided  to  free  the  bowels  by  a  simple  enema 
of  olive  oil  and  warm  water,  to  support  the  strength  by  strong  beef- 
tea  and  abundance  of  milk,  four  ounces  of  port  wine  and  moderate 
doses  of  quinine. 

September  14th  (11th  day). — The  enema  acted  twice,  bringing 
away  dark,  solid  faeces  in  considerable  quantity.  There  was  a 
slight  remission  of  fever,  the  morning  temperature  being  103°. 

September  loth  (12th  day).— She  spent  a  sleepless  night,  being 
very  restless  and  moaning  constantly.  The  heart  was  becoming 
rapidly  weaker — the  impulse  was  feeble,  the  first  sound  indistinct, 
the  second  relatively  strong — being  thrown  into  relief  by  the  sub- 
sidence of  the  systolic  sound.  Strychnin  and  digitalis  were  added 
to  the  quinine  mixture;  and  the  port  wine,  which  had  been 
increased  to  8  ounces  the  previous  day,  was  further  increased  to  12 
ounces,  with  4  Ounces  of  whisky.  The  heart's  action  was  impeded  by 
tympanites,  to  combat  which  a  turpentine  enema  was  administered. 
It  acted  once,  with  some  relief  to  the  patient.  The  persistent 
sleeplessness  and  increasing  head  symptoms  led  me  to  try,  cautiously, 
tartar  emetic  and  opium,  as  recommended  by  Dr.  Graves.  Only 
two  doses,  however,  were  taken — too  small  a  quantity  to  induce 
sleep  on  the  one  hand,  or  to  be  accused  of  injuring  the  patient  on 
the  other.  One-sixth  of  a  grain  of  tartarated  antimony  and  10 
minims  of  tincture  of  opium  alone  were  given. 

September  16th  (13th  day). — She  passed  a  sleepless  night,  with 
much  muttering  delirium.  The  tongue  was  moist ;  but  there  was 
progressive  failure  of  the  heart.  Its  action  was  very  weak — quite 
foetal  in  character.  Port  wine,  §xii. ;  whisky,  §vi.  Towards 
evening  the  temperature  began  to  fall  with  an  attempt  at  crisis. 
At  7.30  p.m.  there  were  marked  cerebral  symptoms  ;  but  in  the 


TYPHUS    FEVER.  2G7 

night  the  bowels  moved,  and  both  diaphoresis  and  diuresis  occurred, 
so  that  an  evident  effort  at  crisis  was  made. 

September  17th  (14th  day). — The  morning  temperature  was 
moderate— 102°  ;  but  this  one  favourable  symptom  was  accompanied 
by  a  rise  in  the  rate  of  both  pulse  and  respirations— a  circumstance 
of  evil  omen.  The  rash  was  on  this  day  evidently  fading  from  the 
anterior  aspect  of  the  body,  although  it  remained  very  petechial 
even  in  this  situation. 

September  18th  (15th  day). — The  temporary  remission  of  pyrexia 
was  now  succeeded  by  an  exacerbation  in  the  symptoms — a  morning 
temperature  of  103*7°,  constipation,  commencing  retention  of  urine, 
and  persistence  of  the  rash.  The  increased  meteorism  obliged  us 
to  order  another  turpentine  enema,  which  operated  once. 

September  19th  (16th  day). — Another  pseudo-crisis  occurred  on 
this  day,  with  profuse  diaphoresis,  and  a  fall  of  temperature  to 
101 '7°.  Again  there  was  a  complete  want  of  accordance  in  the 
symptoms — the  respirations  remained  as  fast  as  ever  (48  per 
minute),  the  pulse  fell  only  four  beats  per  minute,  there  was  com- 
plete retention  of  urine.  The  pulse  could  scarcely  be  counted, 
owing,  first,  to  weakness ;  secondly,  to  the  intensity  of  the  sub- 
sultus  which  was  present.  The  urine  was  now  slightly  albuminous, 
and  the  urea  was  partially  decomposed — the  fresh  urine,  drawn 
off  by  the  catheter,  effervescing  briskly  on  the  addition  of  dilute 
nitric  acid. 

September  20th  (17th  day). — In  no  way  better,  in  some  respects 
worse ;  temperature  rising  ;  bowels  costive,  with  tympanites. 

September  21st  (18th  day). — Morning  temperature,  104*8°; 
pulse,  122  to  126  ;  bowels  have  not  acted  ;  no  return  of  power  over 
the  bladder ;  the  urine  is  drawn  off  by  catheter  every  eight  hours, 
or  oftener.  A  turpentine  enema  was  ordered,  and  to  omit  the 
3-minim  doses  of  liquor  strychnine  which  she  has  been  taking. 
In  the  evening  a  third  abortive  attempt  at  crisis  reduced  the 
temperature  to  103*2°,  but  the  pulse  remained  unaffected. 

September  22nd  (19th  day). — Much  worse  in  every  particular  ; 
unconscious,  with  coma  vigil ;  pupils  contracted  and  sluggish  to 
stimulus  of  light ;  considerable  albuminuria ;  morning  temperature, 


268 


TYPHUS   FEVER. 


106*4°.  Ordered :  one  grain  doses  of  camphor  and  musk  every 
second  hour.  At  6*45  p.m.  I  visited  her  again.  She  was  bathed 
in  a  cold  perspiration  ;  the  extremities  were  cold,  her  eyes  fixed, 
with  coma  vigil ;  bronchial  rales  heard  universally  over  the  chest ; 
axillary  temperature  (taken  twice  with  two  reliable  thermometers) 
was  108'6°.  She  was  manifestly  dying.  At  7  30  p.m.  the  last 
observation  on  the  temperature  was  made ;  it  was  found  to  be 
109-1°.  Three  hours  later  she  was  dead.  Unfortunately  no 
observation  was  made  after  death.  This  was  partly  owing  to  the 
late  hour  at  which  she  died. 


Clinical  Chart  of  Temperature,  &c. 
M.  T. ;  Age,  38  ;  Disease,  Typhus  Fever;  Result,  Death  on  \§th  day. 


Day  of 
Month 

Sept. 

12 
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15 

16 

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18 

19 

20 

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106° 
105° 
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It- 

Pulse  {*; 
Resp.  £■ 

120 

124 

120 

120 

123 

126 

13+ 

1 36 

136? 

130 

136 

128 
134 

124 
124 

118 
124 

122 

124 

120 
I48? 

— 

28 

24 
30 

28 
30 

3+ 

40 

44 

48 

48 
48 

44 

53 

48 

5° 

4S 
53 

46 

48 

44 
48 

— 

Motions 

0 

2 

0 

I 

I 

0 

I 

0 

0 

I     1     ? 

- 

TYPHUS    FEVER.  2l>9 

Authenticated  temperatures  as  high  as  those  noted  in  this  in- 
stance— namely,  108'6°  and  109"1° — are  so  rarely  recorded  that  I 
was  induced  to  bring  forward  the  foregoing  "  Clinical  Record."  So 
far  as  I  am  aware,  no  such  temperatures  had  been  observed  in  the 
Meath  Hospital  since  the  modern  introduction  of  Medical  Thermo- 
metry. In  a  valuable  appendix  to  Dr.  Stokes'  work  on  Fever,  my 
colleague,  Dr.  Arthur  Wynne  Foot,  gives  a  resume  of  thermo- 
metrical  observations  in  the  medical  wards  of  that  hospital  during 
the  three  years,  1871,  1872,  and  1878.  Among  9,248  observations, 
the  highest  reading  noted  was  107"2°.  He  says  : — "  On  27  occa- 
sions temperatures  of  105°  Fahr.  or  upwards  were  registered  in 
typhoid  fever  in  15  patients,  and  of  the  15  patients  in  whom  the 
temperature  on  one  or  more  occasions  reached  105°  Fahr.  or 
upwards,  five  died."  The  highest  temperature  recorded  was  in  "  a 
girl  aged  16  ;  temperature  on  30th  morning  107-2°  Fahr. ;  died  on 
the  31st  evening.  Her  mean  temperature  (51  observations)  during 
the  twenty-six  days  she  was  in  hospital  was  103*lo  Fahr.  The 
morning  temperature,  107 '2°,  was  coincident  with  severe  rigors, 
preceded  by  violent  pain  in  the  abdomen,  ushering  in  peritonitis, 
not  due  to  perforation,  but  to  propagation  outwards  of  the  irrita- 
tion arising  from  numerous  and  extensive  ulcerations  of  the  intestinal 
glands." 

Dr.  Murchison,8,  speaking  of  the  temperature  in  typhus,  observes 
that  "  a  severe  case  is  often  characterised,  not  merely  by  a  high 
temperature  in  the  first  week,  but  by  an  anomalous  or  irregular 
range  in  the  second ;  for  example,  by  an  absence  of  the  morning  fall, 
or  by  a  sudden  fall  with  rise  of  pulse,  or  with  no  improvement  in  the 
general  symptoms.  In  fatal  cases  there  is  usually  a  rise  of  two  or  more 
degrees  just  before  death  or  in  the  death-agony" 

I  have  italicised  the  latter  part  of  this  passage,  as  it  bears  so 
directly  on  the  present  case,  and  is  so  fully  illustrated  by  it. 

Wunderlich  b  remarks  that  "  Fatal  cases  of  exanthematic  typhus 
generally  announce  themselves  even  from  the  very  beginning  by 

a  The  Continued  Fevers  of  Great  Britain.     Third  Edition.     1884. 
b  Medical  Thermometry.    Translated  by  W.  Bathurst  Woodman,  M.D.    The 
New  Sydenham  Society.     1871.     Page  331. 


270  TYPHUS    FEVER. 

the  enormous  height  of  the  temperature  (41*2°  C.  =  106*16°  Fahr., 
and  even  more).  The  transient  remission  at  the  end  of  the  first 
week  is  wanting  in  these  cases.  Death  may  occur  in  the  second 
week  with  continual  high  temperatures.  If  the  case  enters  the 
third  week,  some  remission  may  show  itself  on  the  fourteenth  day,  but 
this  must  not  be  regarded  as  a  favourable  symptom,  and  is  very  soon 
compensated. 

"  Yet  even  in  fatal  cases  the  temperatures  in  the  third  week  are  not 
so  high  as  at  the  earlier  periods,  at  least  till  near  the  death-agony.  The 
daily  maxima  do  not  exceed  40*8°  C.  (105-44°  F.),  but  are,  for  the 
most  part,  moderate.  The  danger  to  life  during  this  third  week 
is  indicated  not  by  the  height  of  the  fever,  but  by  its  continuance. 

"  Just  before  death,  and  in  the  death-agony,  the  temperature  constantly 
rises  in  exanthematic  typhus.  In  all  my  cases  in  which  it  was  possible 
to  make  observations,  there  was  a  rise  of  temperature  during  the 
agony  of  at  least  1*25°  C.  =  2*2°  F.,  in  one  case  of  even  3*6° 
(6-48°);  and  on  an  average  about  1-8°  C.  (3*24  F.).  During  the 
agony  the  temperature  was  seldom  so  low  as  40°  (104°  F.)  ;  more 
usually  it  was  about  41°— 42°  C.  (105*8°— 107'6°  F.),  and  once 
43°  C.  (109-4°  F.)." 

The  curves  of  temperature  in  this  last  case  are  given  in  Table  IV. 
at  the  end  of  Wunderlich's  book,  and  are  also  to  be  found  in  Dia- 
gram VII.  in  Murchison's  work,  where  the  case  is  described  as  one 
of  "  Typhus  fatal  on  17th  day,  with  very  hiqh  temperature  (109*4°  F.) 
before  death?  The  chart  is  strikingly  like  that  which  is  the  subject 
of  the  preceding  "  Clinical  Record." 

The  dread  significance  of  such  temperatures  is  aptly  expressed 
by  Wunderlich  in  his  definition  of  "  Hyperpyretic  Tempera- 
tures" a — those  "  which  in  every  known  disease,  except  relapsing 
fever,  in  all  probability  indicate  a  fatal  termination — 107*6°  F. 
(42°  C.)  or  more." 

a  Loc.  cit.     Pasre  7. 


271 


CHAPTER  XXVIII. 
Analysis  of  the  Chief  Symptoms  of  Typhus. 

The  Surface  :  Fades  typhosa. — Skin  :  maculae  or  petechiae,  sudamina, 
herpes,  poisonous  odour,  which  is  most  infectious  ;  branny  desquamation, 
atrophy  of  nails,  laches  bleudtres,  purpura  spots,  vibices,  profuse  sweating — an 
ominous  form  of  crisis. — Circulatory  System  :  Pulse,  vital  condition  of  the 
Heart — Dr.  Stokes's  views — Question  of  stimulants.  — Respiratory  System  : 
Rate  of  breathing — varieties  of  respiration — Hypostatic  congestion — Breathing 
offensive. — Digestive  System  :  Anorexia,  boubmia  in  convalescence — Condi- 
tion of  the  tongue — "  Parrot  Tongue  " — Sordes  —Diarrhoea. — Urinary  System  : 
Characters  of  the  urine. — Nervous  System  :  Headache,  delirium,  mental 
state,  wakefulness,  "  coma-vigil  "  (Chomei),  "  coma-vigil "  (Jenner),  loss  of 
muscular  strength,  decubitus,  muscular  paralysis,  agitation,  rigidity,  general 
convulsions. — Lesions  op  Organs  op  Special  Sense  :  The  eye,  ear,  nose, 
taste,  sensibility  of  the  skin. 

We  will    now  briefly  consider  the   different  parts  or  systems  of 
the  body  as  affected  by  typhus. 

I.  The  Physiognomy. —The  expression  of  typhus — the  facies 
typhosa — is  characteristic.  From  the  outset  the  patient  looks 
dull  and  heavy.  Afterwards  the  aspect  is  vacant  and  bewildered, 
sometimes  wild  and  defiant.  The  face  is  flushed,  with  a  dusky, 
earthy,  or  leaden  hue.  The  conjunctivae  are  suffused,  the  tongne 
is  dry  and  brown,  sordes  coat  the  lips,  gums,  and  teeth.  Such  is 
the  physiognomy  of  bad  typhus. 

II.  The  Surface. — The  skin  is  covered  with  macula?  or  petechiae 
in  proportion  to  the  severity  of  the  attack.  "The  quantity  of  the 
eruption,"  says  Murchison,  "  its  depth  of  colour,  and  the  earliness 
with  which  it  becomes  livid  or  petechial,  are  in  a  direct  ratio  to 
the  severity  of  the  case."  All  writers  on  typhus  are  agreed  as  to 
the  ominous  significance  of  a  copious,  livid,  and  petechial  rash,  and 
as  to  the  mild  nature  of  non-maculated  cases.  The  skin  is  of  a 
dirty  congested  hue,  deepening  into  a  leaden  or  livid  tint  along 
the  sides  of  the  body  and  over  the  back.  Sudamina,*  or 
sweat  vesicles,  and  local  eruptions  of  herpes  are  not  uncommon. 

a  Lat.  Sudamen,  sweat. 


272  TYPHUS   FEVER. 

A  poisonous  odour  hangs  about  the  skin  of  the  typhus  patient 
after  the  first  week.  It  is  most  infectious.  Lind  compared  it  to 
the  smell  of  rotten  straw.  Gerhard  well  described  it  as  "  pungent, 
ammoniacal,  and  offensive."  Barrallier  likened  it  to  the  odour 
developed  by  rubbing  the  leaves  of  rue  between  the  fingers. 
Murchison  thinks  it  more  correct  to  speak  of  it  as  a  smell  sni 
generis.  This  typhus  odour  is  strongest  in  damp  weather  and 
when  the  ventilation  is  deficient. 

The  forms  which  the  true  typhus  eruption  assumes  have  been 
already  described,  as  well  as  the  date  on  which  it  appears,  and  the 
percentage  frequency  of  its  presence.  It  only  remains  to  mention 
that  the  rash  comes  out  once  and  for  all,  not  in  successive  crops, 
like  the  rose-spots  of  typhoid,  and  that  the  spots  remain  visible  for 
a  week  or  ten  days.  Desquamation  takes  place  in  fine  branny 
scales,  especially  when  the  skin  has  presented  a  general  erythema- 
tous blush.  A,  Vogel a  has  described  and  figured  a  white  band  and 
a  furrow  which  often  appear  at  the  lunula  of  the  nails  four  to  six 
weeks  after  the  commencement  of  the  fever  and  gradually  advance 
to  the  tip.  The  hair  usually  falls  off  in  convalescence.  The  occa- 
sional appearance  of  the  so-called  taches  bleudtres  is  of  no  clinical 
importance. 

Purpura  spots  aud  vibices  are  also  seen  in  certain  bad  forms  of 
typhus,  especially  when  complicated  with  scurvy.  This  often  hap- 
pened in  the  Crimea,  according  to  Jacquot.  The  purpura  spots 
are  independent  of  the  characteristic  petechias  of  typhus,  although 
both  are  subcutaneous  ecchymoses. 

The  skin  is  generally  dry  and  hot  from  an  early  stage  until 
crisis,  which  is  often  accompanied  by  moderate  perspiratiou.  A 
profuse  sweat  is  an  ominous  form  of  crisis.  In  several  cases,  for 
the  most  part  fatal,  Murchison  found  that,  on  evaporation,  the 
sweat  left  a  white  efflorescence  upon  the  eyelids  and  face.  This 
consists  of  rod-shaped  and  stellate  crystals,  composed  of  a  free  acid, 
fatty  matter,  and  a  large  proportion  of  chlorides.  Barrallier  made 
a  similar  observation  in  the  Toulon  epidemic  of  1861. 

a  Die  Nagel  nach  fieberhaften  Krankhtiten.  Deutsch.  Arch,  fur  klin.  Med. 
1870.     Page  333. 


TYPHUS    FEVER.  273 

III.  Circulatory  System. — The  circulation  is  much  disturbed. 
The  pulse  is  at  first  full,  but  soft  and  compressible,  and  moderately 
quickened,  to  108,  112,  or  120  beats  per  minute.  Occasionally 
it  is  abnormally  slow — down  to  48,  40,  and  even  30  beats.  This 
is  often  a  sign  of  debility.  The  impulse  of  the  heart  and  the  pulse 
beat  do  not  always  correspond  in  rate,  some  of  the  systolic  waves 
failing  to  reach  the  radial  artery,  so  that  tlie  heart  may  beat  twice 
for  every  stroke  of  the  radial  pulse.  The  pulse  always  becomes  more 
rapid  and  less  full  when  the  patient  sits  up  or  attempts  to  stand, 
positions  which  should  never  be  assumed  by  the  typhus  patient. 
In  severe  cases  the  pulse  becomes  undulatory  or  dicrotous  in  the 
second  week.     This  is  an  indication  of  very  low  arterial  tension. 

The  vital  condition  of  the  heart  is  profoundly  altered  in  this 
fever.  It  is  to  Dr.  Stokes  that  we  are  indebted  for  a  full  clinical 
account  of  febrile  weakening  of  the  heart.a  According  to  Louis,  the 
typhous  softening  of  the  heart  preponderated  in  the  left  ventricle. 
Hence,  the  first  sound  was  weakened.  Sometimes  both  ventricles 
were  engaged,  and  then  the  first  sound  would  disappear.  In  a  case 
of  "  malignant  fever,"  observed  by  Dr.  Stokes  in  the  Meatli 
Hospital  many  years  ago,  the  patient  (a  woman)  became  pulse- 
less at  the  wrist,  while  the  heart  beat  rapidly  and  forcibly.  Trans- 
fusion of  human  blood  was  tried,  and  the  patient  rallied.  The 
experiment  not  being  repeated,  death  took  place.  Dissection 
showed  that  the  body  was  absolutely  bloodless.  From  this  obser- 
vation Stokes  concluded  that  the  blood  passing  through  the  ven- 
tricle had  very  little  to  say  to  the  making  of  the  first  sound. 

Weakening  of  the  heart  generally  commences  about  the  fourth 
or  fifth  day  of  typhus,  and  begins  to  subside  about  the  tenth  day. 
The  first  symptom  is  a  diminished  cardiac  impulse,  even  when  the 
patient  lies  partly  on  the  left  side,  so  as  to  bring  the  apex  of  the 
heart  in  contact  with  the  chest  wall.  The  impulse,  in  the  next 
place,  fails  altogether,  while  the  first  sound  diminishes  in  loudness. 

a  Cf .  Researches  on  the  State  of  the  Heart  and  on  the  use  of  Wine  in  Fever.  Dubl. 
Jour,  of  Med.  Science.  Vol.  XII.  1839.  Also  Diseases  of  the  Heart  and 
Aorta.  1854.  Page  366.  And  Lectures  on  Fever.  London :  Longmans 
Green  &  Co.     1874.     Pages  185,  et  sea. 

T 


274  TYPHUS    FEVER. 

These  signs  are  most  apparent  towards  the  left  side,  because  the 
left  ventricle  is  most  affected.  Occasionally  the  first  sound  is 
accompanied  by  a  temporary  bellows-murmur.  The  third  stage  is 
disappearance  of  the  first  sound,  the  heart  beating  with  only  one, 
and  that  the  second  sound,  which  by  contrast  may  appear  to  be 
even  accentuated.  It  may,  however,  be  positively  increased 
owing  to  tension  in  the  pulmonary  artery.  In  a  yet  more  advanced 
stage  of  cardiac  weakness  both  sounds  are  equally  diminished  in 
loudness,  and  become  equi-distant,  while  the  heart  beats  with 
great  rapidity  (140-160  per  minute).  To  this  state  the  term 
foetal  heart  is  applied,  because  in  its  weakness  and  quickness  it 
resembles  the  heart-beat  of  the  foetus  in  utero.  This  condition 
indicates  extreme  debility.  The  last  stage  of  all  is  silence  of  the 
heart,  a  sign  of  impending  dissolution — as  Stokes  observes,  a  con- 
dition which  is  almost  invariably  fatal.  It  should  be  remarked 
that  the  influence  of  a  very  muscular  or  a  very  fat  chest-wall  must 
be  allowed  for,  if  present,  when  a  physical  examination  of  the 
heart  is  made.  When  loud  bronchial  rales  and  rhonchi  are  audible 
the  heart  sounds  may  also  be  concealed. 

Should  the  patient  recover,  the  physical  signs  alter  in  the 
inverse  order.  Coincidently  with  the  return  of  the  first  sound,  the 
pulse  should  fall  in  rate,  otherwise  the  prognosis  is  bad.  After 
the  fever  symptoms  have  vanished  the  pulse  often  falls  much  below 
the  normal  rate — even  as  low  as  30  beats  in  the  minute,  and  then 
slowly  recovers  itself. 

Dr.  Stokes  points  out  that  in  fatty  degeneration  of  the  heart,  or 
after  a  bite  from  the  rattlesnake,  wine  may  be  taken  in  almost  any 
quantity  without  producing  head  symptoms.  From  this  he  adduces 
an  argument  for  the  free  use  of  wine  in  fever.  At  the  same  time  he 
shows  that  when  recovery  of  the  heart  coincides  with  an  increasing 
rate  of  the  pulse,  stimulants  are  almost  certainly  doing  harm— they 
must  be  omitted  and  at  once. 

IV.  Respiratory  System.— (1).  As  is  well  known,  the  ratio 
which  the  respirations  bear  to  the  pulse-rate  is  in  health  1  to  4— 
that  is,  18  respirations  per  minute  correspond  to  a  pulse-rate  of  72 
per  minute.     In  typhus,  where  there  is  no  pulmonary  complication 


TYPHUS    FEVER.  275 

of  account  and  where  the  nervous  symptoms  are  not  pronounced, 
this  ratio  is  commonly  maintained.  Thus  a  pulse  of  120  would 
mean  30  respirations  a  minute.  In  grave  cases,  however,  certain 
abnormal  characters  of  respiration  may  arise  from  cerebral  disturb- 
ance independently  of  any  pulmonary  complications.  Thus  the 
breathing  in  such  cases  is  hurried,  sighing,  irregular,  spasmodic, 
'or  jerking  (Murchison).  There  is,  as  Hudson a  expresses  it,  a 
besoin  a  respirer,  what  the  Germans  call  Lujthunger.  This  irre- 
gularity of  breathing,  independent  of  any  pectoral  affection,  Graves1- 
was  in  the  habit  of  calling  "  cerebral  respiration."  In  other  cases 
the  breathing  is  irregular,  blowing,  or  hissing,  while  the  mouth  is 
kept  closed,  the  cheeks  puff  out,  and  the  nostrils  dilate  with  each 
expiration — this  is  the  "  nervous  or  cerebral  respiration  "  of  Sir 
Dominic  Corrigan.  A  third  variety  is  the  rising  and  falling 
breathing,  to  which  the  name  of  "  Cheyne-Stokes  respiration " 
has  been  given. 

(2).  Hypostatic  Congestion  takes  place  in  the  most  dependent 
parts  of  the  lungs  in  consequence  of  impaired  innervation  (para- 
lysis of  the  pneumogastric  nerves),  impaired  nutrition  of  the  blood 
vessels,  and  lessened  heart  power.  Its  occurrence  is  largely  de- 
termined by  the  way  in  which  the  patient  lies — as,  for  example 
on  the  back  {dorsal  decubitus).  At  the  same  time  serum  is  effused 
into  the  pulmonary  tissue  (serous  oedema  of  the  lungs),  and  effusion 
also  takes  place  into  the  bronchi  and  bronchioles.  This  dangerous 
state  of  things,  as  a  rule,  betrays  its  development  by  neither  cough 
nor  expectoration,  the  chief  symptoms  being  rapid,  laboured  breath- 
ing (30,  40,  50,  or  even  60  respirations  each  minute)  and  cyanosis 
due  to  defective  aeration  of  the  blood.  The  surface  is  livid  cold 
and  clammy,  and  the  patient  passes  from  stupor  into  coma. 

Physical  examination  of  the  chest  day  by  day  affords  timeliest 
warning  of  the  stealthy  approach  of  this  perilous  condition,  and 
should  never  be  neglected  in  typhus.  The  patient  should  not  be 
raised  in  bed  for  this  examination,  but  gently  and  slowly  turned 

a  Lectures  on  the  Study  of  Fever.     Second  Edition.     1863.     P.  100. 
b  Clinical  Lectures  on  the  Practice  of  Medicine.      New  Sydenham  Society 
Edition.     Vol.  I.,  page  177.     1884. 


276  TYPHUS   FEVER. 

* 

from  side  to  side,  while  still  in  the  recumbent  position.  Further, 
in  order  to  protect  himself  from  infection,  the  physician  should 
allow  fresh  air  to  play  for  a  moment  about  the  patient's  person 
before  applying  his  ear  to  the  back  of  the  chest.  A  stethoscope 
with  a  long  double  stem  should  also  be  employed  for  auscultation. 
The  physical  signs  are — First,  a  few  coarse  crepitating  rales  with, 
it  may  be,  abnormal  clearness  on  percussion  probably  due  to' 
relaxation  of  lung  tissue.  The  rales  are  then  heard  all  over  the 
back  and  front  of  the  chest,  and  increasing  dulness  on  percussion 
may  be  detected  with  feeble,  but  not  tubular  breathing. 

The  breath  of  a  typhus  patient  is  offensive,  heavy,  and  pungent, 
with  a  smell  which  has  been  likened  to  that  of  yeast.  The  propor- 
tion of  carbon  dioxide  (C02)  in  the  expired  air  of  typhus  was 
shown  by  Dr.  A.  Malcolm,a  of  Belfast,  in  1843,  to  be  considerably 
below  the  normal  amount.  This  anomalous  result  is  explained  by 
Vierordt's  observation  that,  even  in  health,  the  proportion  of  car- 
bonic acid  in  the  expired  air  diminishes  as  the  respirations  increase 
in  frequency.  Leyden  of  Kbnigsberg b  also,  while  confirming 
Malcolm's  statement  that  the  percentage  of  carbon  dioxide  in  the 
expired  air  of  typhus  is  diminished,  found  the  absolute  quantity 
increased  by  one  half.  In  severe  cases  the  breath  has  often  an 
ammoniacal  odour,  and  Murchison's  observations  led  him  to  think 
that  both  in  uramiia  and  in  typhus  the  expired  air  may  contain 
ammonia  independently  of  the  condition  of  the  mouth  and  pharynx. 
He  figures  some  very  beautiful  dendritic  (tree-like)  crystals  of  chlo- 
ride of  ammonium  obtained  by  holding  a  glass  rod  moistened 
with  hydrochloric  acid  before  the  mouth  and  nostrils  of  typhus 
patients. 

V.  Digestive  System. — The  appetite  fails  completely  from  the 
outset,  and  this  anorexia  c  persists  until  crisis,  when  a  return  of 
appetite  is  one  of  the  first  signs  of  approaching  convalescence.  In 
fact,  there  is  an  intense  craving  for  food  and  an  enormous  appetite 

a  Edinb.  Monthly  Journ.  of  Med.  He.     Vol.  III.     1843. 

b  E.  Leyden.  "  Ueber  die  Respiration  im  Fieber."  Deutsch.  Arch,  fur  Klin. 
Med.     1870.     Page  536. 

c  Gk.  avope^ia,  want  of  appetite.  From  av-,  priv.,  and  opt^is,  a  longing  or 
yearning  for  anything. 


TYPHUS    FEVER.  277 

(boulimia)  a  during  recovery.  The  tongue  is  at  first  large,  pale, 
and  coated  with  a  white  fur,  which  soon  becomes  yellowish  brown  ; 
it  afterwards  shows  a  dry,  brown  streak  in  the  centre.  At  a  still 
later  stage  of  the  bad  cases  it  is  thickly  studded  with  sordes,  becomes 
black  and  shrunken,  and  cannot  be  protruded,  but  catches  behind 
the  lower  teeth.  In  this  condition  it  is  described  as  the  "  parrot 
tongue"  of  typhus.  Occasionally  it  is  red,  with  enlarged  papilla?, 
but  scarcely  ever  is  it  glazed  and  fissured  like  the  tongue  of  typhoid 
or  enteric  fever. 

The  amount  of  dryness  and  darkness  of  the  tongue  is,  according 
to  Murchison,  a  fair  criterion  of  the  severity  of  the  case.  When 
stimulants,  however,  are  given  in  excess  the  tongue  is  apt  to  become 
dry  and  brown.  The  sordes  which  gather  on  the  lips,  gums,  and 
teeth,  as  well  as  on  the  tongue  in  the  second  \veek,  consist  of  pro- 
liferated epithelium,  which  has  desquamated  quickly,  fragments  of 
food,  various  micro-organisms,  dried  mucus,  saliva,  and  blood. 
This  mixture  becomes  black  from  desiccation. 

Nausea  and  vomiting  are  rare  in  typhus,  so  also  is  meteorism  or 
tympanites.  Gurgling  (gargouillement)  in  the  ileo-caecal  region, 
tenderness  on  pressure  in  this  situation,  intestinal  haemorrhage, 
and  diarrhoea,  are  all  exceptional  in  typhus.  Sometimes,  however, 
the  bowels  are  loose,  especially  about  the  time  of  crisis.  Consti- 
pation, however,  is  the  rule  in  typhus.  Both  liver  and  spleen  may 
be  enlarged,  as  in  other  acute  infective,  or  specific,  diseases.  When 
diarrhoea  prevails,  the  motions  become  strongly  alkaline  in  reaction, 
and  contain  many  prismatic  crystals  of  triple  (ammonio-magnesian) 
phosphate. 

VI.  Urinary  System. — The  renal  secretion  is  much  diminished  at 
first.  It  is  acid,  dark-coloured,  and  of  high  density  (1024-1030). 
The  coloration  is  due  partly  to  concentration  but  still  more  to 
escape  of  blood-pigment,  the  result  of  typhous  dissolution  of  the  blood. 
Towards  the  close  of  the  fever  there  may  be  diuresis,  with  a  copious 
precipitation  of  urates  or  lithates.  Urea  is  increased  in  quantity 
at  first,  but  afterwards  falls  below  normal.  This  is  due,  notwith- 
standing the  disintegration  of  the  nitrogenous  tissues,  to  low  diet 

a  Gk.  0ov\tfjLia,  ravenous  hunger. 


L'<8  TYPHUS    FEVER. 

and  imperfect  elimination.  In  a  "  Note  on  the  Relation  between 
Urea  and  Fever,"  communicated  to  the  Tenth  International  Con- 
gress at  Berlin,  Professor  Horatio  C.  Wood  and  Professor  John 
Marshall,  of  the  University  of  Pennsylvania,  stated  that  it  seemed 
to  them  "  not  yet  definitely  decided  whether  increase  of  urea  elimi- 
nation is  an  integrant  part  of  the  fever  process,  or  whether  it  is  an 
indirect  outcome,  caused  by  the  action  of  the  excessive  heat  upon 
certain  organs,  or  other  disarrangements  of  the  bodily  functions." 
In  their  paper,  the  authors  point  out  one  important  fallacy  which 
must  be  guarded  against — namely,  the  tendency  to  consider  tem- 
perature as  a  measure  of  fever,  using  the  term  "  Fever "  in  its 
proper  sense  to  express  "  the  abnormal  nutritive  process,  the  out- 
come of  which  is  often  elevated  temperature."8.  There  is  reason 
to  believe  that  the  presence  of  urea,  or  some  other  derivative  of 
albumen,  in  the  blood  will  give  rise  to  delirium,  stupor,  and  coma, 
as  well  as.  to  the  ammoniacal  odour  given  off  by  the  skin. 

Albuminuria  is  often  present,  but  this  does  not  necessarily  imply 
renal  disease,  for  in  excessive  blood-changes  such  as  occur  in  bad 
typhus,  the  blood-serum  may  find  its  way  into  the  urine.  Tube- 
casts,  however,  are  not  uncommonly  found  on  microscopical  exami- 
nation. Murchison  suggests  that  possibly,  in  some  cases,  the 
albuminuria  may  be  due  to  the  presence  of  albumen  in  excess  in 
the  blood  from  disintegration  of  the  tissues,  which  the  glandular 
structures  have  been  unable  to  convert  into  urea. 

Chlorides  gradually  diminish  from  the  outset,  so  that  absence  of 
chlorides  from  the  urine  cannot  be  regarded  as  pathognomonic  of 
acute  pneumonia,  as  has  been  supposed. 

Uric  acid  is  usually  increased,  and  both  Frerichs  and  Murchison 
have  detected  leucin  (C6Hi3N02)  and  tyrosin  (C9HUN03),  two 
products  of  the  disintegration  of  albumen  or  fibrin  in  the  urine  of 
typhus. 

VII.  Nervous  System. — Frontal  headache  is  an  early  and  con- 
stant symptom.  It  is  a  dull,  aching,  heavy  pain — rarely  acute, 
darting,  stabbing,  throbbing,  or  bursting.     It  is  the  most  charac- 

a  Verhandlungen  des  X.  Tntemationalen  medieinisrhen  Congresses.  Band 
II.     Abtheilung  II.  :  "  Physiologie  und  physiologische  Chemie. "     40. 


TYPHUS    FEVER.  279 

teristic  nervous  symptom  during  the  first  week  of  typhus.  Vertigo 
and  rheumatoid  pains  in  the  back  and  limbs,  are  also  present 
during  the  earlier  periods  of  the  fever. 

Mental  confusion  or  actual  delirium  takes  the  place  of  headache 
towards  the  close  of  the  first  week.  Hence  typhus  lias  been  often 
called  "  brain  fever."  The  mind  becomes  blunted  and  dull,  memory 
lapses,  and  cerebration  is  slow  and  defective.  Hence  the  term 
"  typhus."  a 

The  delirium  varies  in  character.  Three  types,  in  particular, 
are  described — (1.)  A  quiet,  listless,  low  muttering  delirium — the 
typhomania  of  Galen  and  early  writers — well  defined  as  "affectus 
ex  phrenitide  et  lethargo  mixtus."  The  patient  is  easily  roused  from 
it  so  as  to  give  either  coherent  or  rambling  answers,  but  soon 
relapses  into  a  torpid  or  semi-unconscious  state.  (2.)  A  more 
busy  form  of  raving,  with  prostration,  restlessness,  and  tremors  of 
the  limbs,  muscles  of  the  face,  and  tongue — like  the  delirium 
tremens  of  the  drunkard.  (3.)  An  acute,  noisy  and  violent  or 
maniacal  frenzy,  in  which  the  patient's  strength  appears  super- 
natural for  a  time,  but  the  outburst  is  succeeded  by  profound 
prostration  or  fatal  collapse.  In  this  form — called  delirium  ferox — 
the  patient  may  exhibit  a  homicidal  or  suicidal  tendency. 

Of  the  three  foregoing  types  the  first  is  the  most  common,  the 
last  is  the  least  common  in  typhus.  One  form  may  pass  into 
another,  or  one  form  may  merge  in  another. 

"The  mental  state  of  the  delirious  typhus  patient,"  writes 
Murchison,  "  is  peculiar,  and  well  worthy  the  study  of  the  meta- 
physician. As  a  rule,  the  memory  is  first  and  most  affected ; 
judgment  and  power  of  connected  reasoning  often  remain  after  the 
memory  has  entirely  gone.  The  mind  may  labour  under  the 
strangest  delusions,  and  often  it  appears  to  revolve  obstinately 
around  some  fixed  idea.  The  patients  rave  about  objects  which 
have  greatly  engrossed  their  attention,  either  immediately  preceding 
the  attack,  or  years  before,  and  which  are  now  jumbled  with 
persons,  scenes,  and  events,  with  which  they  have  had  no  connec- 
tion." He  gives  some  very  graphic  illustrations  of  these  mental 
phenomena  from  his  own  experience  and  that  of  other  authors. 
a  Gk.  Tvfos,  smoke,  or  vapour. 


280  TYPHUS    FEVER. 

Wakefulness  is  a  common  symptom  in  early  typhus.  It  is  apt 
to  be  followed  by  extreme  nervous  agitation  and  prostration,  or  by 
somnolence,  deepening  into  complete  coma,  and  terminating  in 
death. 

Sometimes  a  patient  awakes  from  a  prolonged  sleep  and  insists 
that  he  has  never  closed  his  eyes.  This  condition  is  the  "  coma-vigil" 
of  Chomela — not  of  necessity  a  bad  sign.  But  this  term  is,  unfor- 
tunately, apt  to  mislead,  for  with  more  propriety  it  has  been  applied 
by  Sir  William  Jenner  to  another  condition  of  most  ominous  import. 
In  the  "  coma-vigil"  of  Jenner  the  patient  lies  with  his  eyes  wide 
open,  with  a  vacant  gaze,  his  lips  parted,  his  face  pallid  and  ex- 
pressionless ;  the  pulse  rapid  and  feeble,  or  imperceptible ;  the 
breathing  hardly  to  be  detected ;  the  skin  cold  and  clammy  or 
bathed  in  sweat.  Although  awake,  the  sufferer  is  insensible  and 
surely  dies. 

Loss  of  muscular  strength  is  an  early  and  constant  symptom. 
The  patients  are  not  only  weak,  but  from  the  first  complain  of  a 
feeling  of  feebleness  and  lassitude. 

The  decubitus  is  dorsal.  In  bad  cases  the  patient  sinks  down 
in  the  bed,  his  head  gliding  from  the  pillow. 

Various  muscular  paralyses  are  observed  in  typhus.  Thus, 
paralysis  of  the  neck  of  the  bladder,  coming  on  about  the  10th 
or  11th  day,  will  lead  to  involuntary  dribbling  of  urine;  paralysis 
of  the  sphincter  ani,  to  incontinence  of  faeces.  The  coats  of  the 
bladder  may  lose  their  power  from  over-distension,  causing  reten- 
tion of  urine.  Incontinence  and  retention  may  even  co-exist. 
Meteorism  is  due  to  paresis — that  is,  partial  paralysis — of  the  walls 
of  the  intestines.  The  orbiculares  palpebrarum  may  be  paralysed, 
so  that  the  patient  cannot  close  his  eyelids — so  causing  keratitis 
and  sloughing  of  the  cornea  from  exposure.  Aphonia,  inability 
to  protrude  the  tongue,  and  dysphagia,  are  other  examples  of 
typhous  paralysis — the  last-named  being  the  worst  of  all,  and 
usually  the  forerunner  of  death. 

Muscular  agitation  indicates  great  prostration.  It  is  observed 
in  the  old  and  infirm,  in  the  intemperate,  and  in  brain- workers. 
a  Lemons  de  Clinique  Medicale.     Paris.     1834.     Tome  I. 


TYPHUS   FEVER.  281 

The  forms  it  takes  are — Tremulousness  of  the  hands,  tongue,  or 
whole  body;  rapid  oscillatory  movements  of  the  eyeballs  (nystag- 
mus a)  ;  choreiform  movements  of  the  extremities ;  twitchings  of 
the  tendons  (submltus  tendinum)  of  the  wrist  and  facial  muscles ; 
choreic  convulsions  (Murchison,  one  case ;  Barrallier,  one  case) ; 
picking  at,  or  fumbling  with,  the  bed-clothes  (floccitatio  or  carphology), 
and  obstinate  hiccough  (singultus).  All  these  symptoms  are  of 
grave  import,  and  are  best  marked  in  ataxic  typhus. 

Muscular  rigidity  is  a  much  rarer  phenomenon  than  muscular 
agitation,  although  equally  unfavourable.  The  fingers  may  be 
clenched  or  the  forearms  flexed.  Tonic  spasms  of  certain  muscles 
have  been  observed,  or  even  trismus  or  strabismus.  Well-marked 
opisthotonos,  with  the  head  bent  back  and  the  limbs  rigid,  was 
once  observed  by  Murchison  and  once  by  Perry — both  cases 
proving  fatal. 

General  convulsions  are  most  dangerous  in  typhus.  They  occur 
in  about  one  per  cent,  of  the  cases,  and  with  rare  exceptions  are  of 
uraemic  origin.  In  most  cases  there  is  albuminuria,  with  scanty  or 
suppressed  secretion  of  urine.  Kidney  disease  is  often  present, 
or  there  may  be  an  intemperate  history.  Occasionally,  simple 
retention  of  urine  determines  an  attack.  Uragmic  convulsions  do 
not  usually  appear  before  the  middle  or  end  of  the  second  week. 
The  fit  is  commonly  preceded  by  unwonted  drowsiness  or  delirium, 
occasionally  the  patient  may  seem  to  be  convalescing.  Death  may 
take  place  during  the  fit,  and  in  41  out  of  51  cases  observed  by 
Murchison  it  happened  in  less  than  twenty-four  hours.  If  life  is 
prolonged,  coma  or  a  renewed  attack  may  follow  the  first  fit. 
Hippocrates  b  regarded  convulsions  as  most  dangerous  in  fever,  and 
all  writers  agree  with  this  opinion.  Occasionally,  however,  recovery 
does  take  place.  In  Murchison's  note-books  there  were  records  of 
69  eases  of  typhus  with  convulsions.  Of  these  61  were  fatal,  and 
8  recovered. 

a  Gk.  vva-Tayfi6s,  nodding,  or  drowsiness  ;  from  v vtrrdfa,  to  nod  in  sleep. 
b  Aphorisms.     Bk.    IV.   66,   67.      "E.v  rolffi  irvpeToiaiv  ol  e/c  twv  vttvwv  (p40ot, 
%  <7iraa-fxo\,  ko,k6v.      'Er  roifft  irupiToiai  rb  irvevfia  irpoffKoirTOf,  Kaicbv,  (nrao-/xbv  yap 


282  TYPHUS    FEVER. 

In  Cork-street  Fever  Hospital  during  the  year  ending  March  31, 
1881,  ursemic  convulsions  proved  fatal  in  three  instances,  in  two 
at  least  of  which  there  was  a  distinct  history  of  alcoholism.  It  is 
more  than  a  coincidence  that  there  was  a  marked  tendency  to  cases 
of  this  kind  in  January,  1881 — that  is,  after  the  Christmas  holidays, 
and  during  a  period  of  intense  cold. 

Retention  of  urine  may  give  rise  to  epileptoid  convulsions,  in 
which  case  judicious  treatment  may  afford  immediate  relief.  Sir 
Dominic  Corrigan,  in  his  "  Lectures  on  Fever," a  gives  a  striking 
instance  of  this ;  but  the  following  quotation  from  Dr.  Stokes's 
"  Lectures  on  Fever "  b  will  prove  even  more  interesting.  He 
says  : — "  The  most  long-continued  attack  of  convulsions  I  ever 
witnessed  was  in  the  case  of  a  student  of  this  (the  Meath)  Hospital, 
who  had  gone  on  to  the  thirteenth  day  of  fever.  The  distended 
bladder  could  be  felt,  but  such  was  the  violence  of  the  convulsions, 
attended  with  extraordinary  priapism,  that  all  attempts  at  cathe- 
terism  were  futile.  It  was  also  impossible  to  get  the  patient  to 
swallow  anything,  or  to  use  an  enema,  and  under  these  desperate 
circumstances  we  determined  to  employ  chloroform  inhalation.  The 
greatest  difficulties  attended  the  administration  ;  but,  at  last,  the 
effect  was  produced.  The  convulsions  ceased  like  magic,  and  sud- 
denly a  jet  of  urine  sprang  upwards  to  a  great  height  from  the  still 
erect  penis,  the  stream  continuing  to  flow  until  the  bladder  was 
empty,  when  the  priapism  disappeared. 

"  We  see,  therefore,"  adds  Stokes,  "  that  where  the  uraemic  con- 
dition and  its  accompanying  convulsions  depend  on  mere  retention 
of  urine,  we  have  a  ready  and  efficacious  remedy  in  careful  and 
judicious  evacuation  of  the  bladder  by  the  catheter." 

VIII.  Lesions  of  Organs  of  Special  Sense. — 

1.  The  Eye. — The  conjunctivae  are  generally  injected  with  dark 
blood,  hence  the  expression,  "  the  ferret-eyes "  of  typhus.  The 
pupils  are,  as  a  rule,  contracted,  sometimes  to  a  mere  point — the 
pin-hole  pupil  of  Graves.  This  is  noticed  in  cases  of  acute  deli- 
rium.    When  stupor  is  profound  or  has  deepened  into  coma,  the 

a  Dublin  :  Fannin  &  Co.     1853.     Page  43. 

b  London  :  Longmans,  Green  &  Co.     1874.     Page  421. 


TYPHI'S    FEVER.  289 

pupil  dilates,  and  is  insensible  to  light,  and  slight  strabismus 
occurs. 

Dr.  Cayley  observes  that  inequality  in  the  pupils  is  by  no  means 
an  infrequent  symptom  in  both  typhus  and  enteric  fever.  It  may 
occur  at  any  time,  and  is  apparently  without  prognostic  signifi- 
cance.    He  offers  no  explanation  of  the  phenomenon. 

Photophobia  also  is  not  of  uncommon  occurrence. 

2.  The  Ear. — During  the  first  few  days,  and  also  in  convales- 
cence, tinnitus  aurium  and  noises  in  the  head  are  often  present. 
After  the  fifth  day,  deafness  of  one  or  both  ears  may  occur,  either 
as  part  of  the  general  anaesthesia  of  the  fever,  or  as  a  result  of 
typhous  softening  of  the  intrinsic  muscles  of  the  ear,  according  to 
Dr.  Stokes.  In  some  cases,  otitis  may  be  the  cause  of  the  deafness, 
and  otorrhoea  will  solve  the  question.  Fracastori  (1546)  regarded 
deafness  as  a  favourable  symptom — "  Surditas  salutem  portendit" 
and  Alison,  of  Edinburgh  (1849),  was  of  the  same  opinion.  But 
it  is  only  relatively  true,  morbid  acuteness  of  hearing,  or  intole- 
rance of  sound  being  distinctly  a  bad  sign. 

3.  The  Nose. — The  sense  of  smell  is  blunted,  often  from  catarrh. 
Epistaxis,  or  nose-bleeding,  is  very  rare  in  typhus.  Murchison  met 
with  it  about  a  dozen  times  in  7,000  cases,  and  even  then  it  was 
generally  scanty.  This  is  a  point  of  diagnostic  importance  be- 
tween typhus  and  typhoid  fever. 

4.  Taste. — This  sense  is  perverted  from  the  outset,  and  in 
advanced  and  severe  cases  is  abolished.  Acids  are  longest  relished, 
but  after  a  time  cold  water  is  preferred  (Murchison). 

5.  Sensibility  of  the  Skin. — This  is  usually  lessened,  or  may  be 
lost  towards  the  end  in  grave  cases  (anaesthesia).  On  the  other 
hand,  the  opposite  condition,  hyperesthesia,  is  occasionally 
observed. 


284 


CHAPTER  XXIX. 

Complications  and  Sequelae  of  Typhus. 

Causes  of  Complications  in  Typhus.  Complications  affecting  (1)  the  Res- 
piratory Organs  :  Bronchitis,  pneumonia,  gangrene  of  the  lung,  pleurisy, 
tuberculosis,  haemoptysis,  laryngitis.  (2)  The  Blood  and  Circulation  :  Acute 
haemophilia,  pyaemia,  venous  thrombosis,  phlegmasia  dolens,  arterial  thrombosis 
and  embolism,  heart  diseases.  (3).  The  Nervous  System  :  Meningitis,  mental 
disease,  paralysis,  neuralgic  and  rheumatoid  pains.  (4).  The  Organs  op 
Digestion  :  Erysipelas  of  the  pharynx,  haematemesis,  diarrhoea,  dysentery, 
intestinal  haemorrhage,  jaundice,  peritonitis.  (5).  The  Urinary  Organs  : 
Nephritis,  vesical  catarrh,  haematuria.  (6).  Diseases  of  the  Integuments  and 
Bones  :  (Edema,  bed  sores,  gangrene,  noma  or  cancrum  oris,  ''  hospital  gan- 
grene," buboes.  (7).  Other  Specific  Diseases  :  variola,  scarlet  fever,  diph- 
theria, erysipelas,  typhoid  fever. 

Complications  and  Sequelae  of  Typhus. — 

The  chief  determining  causes  of  the  complications  which  modify 
the  course  of  typhus  are: — (1).  The  weakened  state  of  the  heart ; 
(2).  The  impure  state  of  the  blood  ;  (3).  Constitutional  peculiarities 
and  family  idiosyncrasies ;  and  (4).  The  "  epidemic  constitution  " 
at  a  given  time  or  place. 

I.  Diseases  affecting  the  Respiratory  Organs. — 

"  The  advent  of  pulmonary  complications  in  typhus  is  most 
insidious,  for  the  ordinary  symptoms,  cough  and  expectoration, 
may  be  slight  or  absent,  and  the  patient  is  unable  to  complain  of 
pain  "  (Murchison).  Hence  the  necessity  of  a  daily  careful  inves- 
tigation of  the  chest  in  this  fever. 

1.  Bronchitis,  or,  as  Stokes  preferred  to  call  it,  the  "  Bronchial 
Affection  "  of  typhus,  is  one  of  the  commonest  complications  of 
this  fever — hence  the  names  "  Catarrhal  Typhus,"  given  to  the 
disease  by  Irish  writers,  and  "  Broncho- Typhus,"  or  "Pneumo- 
Typhus,"  of  Rokitansky.a 

"  A  Manual  of  Pathological  Anatomy.  Vol.  IV.,  page  23.  Sydenham 
Society.     London.      1862.     Translated  by  Dr.  Day. 


TYPHUS    FhVER.  285 

Bronchial  catarrh  may  usher  in,  accompany,  or  succeed  an  attack 
of  typhus.  It  is  a  dangerous  complication,  particularly  in  winter — 
first,  because  it  is  almost  certain  to  be  associated  with  more  or  lesa 
hypostatic  consolidation  in  the  lungs;  secondly,  because  the  bron- 
chial secretion  is  likely  to  accumulate  in  the  tubes  and  asphyxiate 
the  patient  in  consequence  of  his  inability  to  cough,  coupled  with 
the  impaired  nutrition  and  paralysis  of  the  muscular  fibres  of  the 
bronchi. 

Although  Stokes a  denied  to  the  bronchial  affection  of  typhus 
the  name  of  "bronchitis,"  he  practically  admitted  that  it  was  bron- 
chitis when  he  spoke  of  it  as  "  a  special  condition  of  the  air-passages, 
secondary  to  the  fever,  the  result  either  of  the  typhous  deposit  or 
of  the  vascularity  with  turgescence  to  which  I  have  already  alluded." 
He  adds :  "I  do  not  know  any  characteristic  difference  between 
the  physical  signs  which  may  occur  in  ordinary  idiopathic  bronchitis 
and  those  which  present  themselves  in  typhus  when  the  air-tubes 
are  engaged."     Surely  this  is  conclusive. 

2.  Pneumonia  is  a  rare  complication  or  rather  sequela  of  typhus. 
It  may  end  in  recovery,  or  in  abscess,  gangrene,  tubercular  phthisis, 
or  fibroid  condensation  (cirrhosis).  It  may  be  distinguished  from 
hypostatic  congestion  (with  which,  however,  it  is  sometimes  asso- 
ciated) by  the  fact  that  the  dulness  is  unilateral  and  by  the  presence 
of  tubular  breathing  and  rusty  sputa. 

Dr.  Stokes,b  in  his  "  Lectures  on  Fever,"  long  ago  drew  attention 
to  a  peculiar  form  of  pneumonia  which  occasionally  seemed  to 
replace — as  it  were — the  symptoms  of  fever,  and  to  which,  accord- 
ingly, he  gave  the  name  of  "aborted"  or  "arrested  typhus." 
But  his  very  graphic  and  striking  description  exactly  corresponds 
to  acute  pneumonia  of  the  apex ;  and,  in  the  light  of  modern  in- 
vestigations, his  cases  of  supposed  arrested  or  aborted  typhus  read 
much  more  like  pythogenic  pneumonia  or  pneumonic  fever  than 
typhus.  It  should  also  be  borne  in  mind  that  this  consolidation  is 
described  as  taking  place  as  early  as  the  fourth  or  fifth  day  of  the 
supposed  typhus,  when  as  yet  there  is  no  typhus  rash,  and  at  a 

a  Lectures  on  Fever.     London  :  Longmans,  Green,  &  Co.     1874.     Page  131. 
b  Loc.  cit.     Page  157,  et  seq. 


286  TYPHUS    FEVER. 

time  when  consolidation  and  even  crisis  are  not  uncommon  in  acute 
pneumonia. 

3.  Gangrene  of  the  Lung,  easily  recognised  by  the  abominable 
foetor  of  the  breath  and  expectoration,  and  by  the  ghastly  and 
pinched  look  of  the  patient,  is  a  rare  and  fatal  complication.  It  is 
apt  to  occur  in  the  most  destitute  patients.  In  one  or  two  cases 
observed  by  Murchison  it  was  secondary  to  extensive  bedsores  over 
the  sacrum,  being  evidently  of  embolic  origin. 

4.  Pleurisy  is  a  rare  and  latent  complication.  The  effusion 
is  generally  purulent  from  the  beginning  as  in  other  specific 
fevers. 

5.  Tuberculosis  of  the  lung  is  also  a  rare  sequela  of  typhus, 
notwithstanding  Stokes's  opinion  to  the  contrary,  based  upon  his 
observations  of  "fever"  cases  which  were  probably  typhoid,  not 
typhus. 

6.  The  occurrence  of  haemoptysis  must  be  considered  as  excep- 
tional. It  results  either  from  tubercular  deposits  or  from  acute 
haemophilia  (Murchison). 

7.  Laryngitis  is  an  infrequent  but  dangerous  complication.  In 
Germany,  Rokitansky  gave  to  the  disease  the  name  of  Laryngo- 
Typhus.  It  may  be  croupal  in  character  or  show  itself  as  acute 
oedema  of  the  glottis.  When  the  inflammation  involves  the  car- 
tilages, it  is  called  "  perichondritis  laryngea." 

II.  Diseases  of  the  Blood  and  Circulatory  Organs: — 

1.  Acute  Haemophilia. — Typhus  patients,  like  smallpox  patients, 
may  from  "dissolution  of  the  blood"  become  "bleeders" — the 
defibrinated  and  devitalised  blood  escaping  from  the  vessels  with 
unwonted  ease.  Hence  the  formation  of  purpura  spots  and  vibices, 
and  the  occurrence  of  epistaxis,  haemoptysis,  haematemesis,  melsena, 
menorrhagia,  and  hematuria,  as  well  as  other  haemorrhages.  This 
tendency  to  bleed  is  most  marked  with  coincident  scurvy  and 
typhus,  as  in  the  French  Army  during  the  Crimean  War  and  in  the 
Epidemic  of  1847-1848,  at  Edinburgh  and  elsewhere. 

2.  Pyaemia,  with  purulent  deposits  in  the  joints,  is  a  rare  and 
very  fatal  complication  about  the  period  of  the  crisis,  or  it  occurs 
as  a  dangerous  sequela  during  convalescence.     It  is  ushered  in  by 


TYPHUS    FEVER.  287 

repeated  rigors,  and  is  accompanied  by  extreme  prostration,  heart- 
failure,  jaundice,  and  profuse  sweating. 

3.  Venous  Thrombosis  occurs  as  an  occasional  sequela,  causing 
Phlegmasia  alba  dolens,  or  White  Leg.  Stokes  held  that  this 
lesion  was  to  be  expected  when  the  pulse  continued  quick  in  con- 
valescence with  no  pulmonary  or  abdominal  complications  to  account 
for  its  doing  so.  In  ten  years  only  one  case  per  800  was  observed 
in  the  London  Fever  Hospital ;  but  it  used  to  occur  much  more 
frequently.  It  is  not  always  a  painful  affection.  The  left  leg  is 
most  usually  affected,  perhaps  owing  to  compression  of,  and  conse- 
quent slowing  of  the  circulation  in,  the  left  iliac  vein  by  the  right 
iliac  artery.  The  swelling  is  firm  and  brawny,  and  at  times 
enormous.     The  skin  is  pallid,  hence  the  term  "  alba." 

Besides  venous  thrombosis,  obstruction  of  the  lymph  channels 
(J.  Warburton  Begbie a),  or  inflammation  of  the  subcutaneous 
areolar  tissue  (diffuse  cellulitis)  may  also  cause  phlegmasia.  The 
swelling  is  then  rugose  and  painless,  as  well  as  firm  and  brawny. 

4.  Arterial  Thrombosis  and  Embolism  are  occasional,  but 
serious,  complications  or  sequels  of  typhus.  They  cause  local 
gangrene,  cancrum  oris,  osseous  necrosis,  abscess  or  gangrene  of 
the  lungs,  and  splenic  infarctions. 

5.  Heart  Diseases. — Both  pericarditis  and  endocarditis  are 
extremely  rare  complications.  Hence,  Dr.  Stokes  could  not 
believe  in  the  inflammatory  nature  of  the  affection  which  led  to 
weakening  of  the  heart  in  typhus.  Murchison  met  with  only  two 
examples  of  pericarditis,  and  one  example  of  endocarditis,  in  this 
fever.  Notwithstanding  the  views  put  forward  by  Stokes,  no  doubt  is 
now  entertained  as  to  the  organic  nature  of  the  changes  which  take 
place  in  the  myocardium  in  typhus.  It  is  an  acute  granular 
disintegration  of  the  muscular  tissue  of  the  heart,  such  as  has  been 
described  above  in  the  account  of  the  pathology  of  scarlet  fever. 
(See  Chapter  XVIIL,  page  178.) 

a  Edinb.  Med.  Journal.     September,  1872. 


288  TYPHUS    FEVER. 

IIL  Diseases  of  the  Nervous  System. — 

1.  Meningitis  is,  undoubtedly,  very  rare  in  typhus  ;  but  cases 
have  been  recorded  by  Corrigan  and  Hudson a  in  Dublin,  J.  B. 
Russell b  in  Glasgow,  Jacquotc  in  the  Crimea,  Roupelld  and 
Murchison  e  in  London.  The  cerebral  symptoms  of  this  fever  are, 
however,  almost  invariably  independent  of  inflammation. 

2.  Mental  Disease — Temporary  Fatuity  and  Mania  are  rare, 
and  very  sad,  sequelae  of  typhus.  Both  at  the  Meath  Hospital  and 
at  Cork-street  Fever  Hospital  I  have  known  mania  to  occur  after 
this  fever,  necessitating  the  removal  of  the  patient  to  a  Lunatic 
Asylum.  Happily,  recovery  generally  follows  at  last,  usually  in 
two  or  three  months. 

3.  Paralysis  also  is  a  rare  sequela.  It  is  most  commonly  ob- 
served as  hemiplegia,  when  it  perhaps  depends  on  "  arterial  throm- 
bosis of  the  central  organs  of  the  nervous  system"  (Murchison). 
Hudson f  mentions  the  occurrence  of  paraplegia,  but  gives  no  illus- 
trative case.  About  the  year  1880,  two  cases  of  this  sequela 
occured  in  the  practice  of  the  Meath  Hospital — one  of  dorsal,  the 
other  of  cervical,  paraplegia.  Both  patients  were  males,  and 
recovery  followed  in  each  instance.  Dr.  Henry  Kennedy5  observed 
a  case  of  general  paralysis  after  petechial  typhus,  the  patient  being 
a  woman  aged  forty-four. 

4.  Muscular  Fains  sometimes  occasion  much  distress  in  conva- 
lescence, and  protract  recovery.  They  are  sometimes  of  a  neuralgic 
character,  but  often  resemble  muscular  rheumatism.  The  former 
*ype  may  be  the  precursor  of  phlegmasia,  gangrene  of  the  feet,  or 
paralysis  (Murchison).  In  some  cases,  the  pains  are  probably 
symptomatic  of  peripheral  neuritis,  which  is  now  known  to  occur 
after  specific  fevers. 

5.  An  interesting  phenomenon  sometimes  observed  in  typhus  or 

a  Lectures  on  the  Study  of  Fever.  By  Alfred  Hudson,  M.D.  Dublin.  1868. 
Second  Edition.     Pages  252    et  seq. 

b  Glasgow  Med.  Journal.    February,  1869. 

c  Du  Typhus  de  V Arm.ee  de  I 'Orient.     Paris.     1858. 

a  A  Treatise  on  Typhus  Fever.     London.     1839.     Pp.  108,  217. 

e  Lancet.     1865.     Vol.1.     Pp.  417,  482. 

'  Loc.  cit.     Page  248.  *  Ibidem. 


TYPHUS   FEVER.  289 

during  convalescence  from  this  fever  is  the  development  of  the 
pathological  deep  reflex  known  as  "ankle-clonus,"  and  the 
exaggeration  of  the  physiological  deep  reflex  called  the  "knee- 
jerk  "  or  "  patellar  reflex." 

IV.  Diseases  of  the  Digestive  Tract. — 

1.  Erysipelas  of  the  Pharynx  is  met  with  in  some  cases,  causing 
dysphagia  and — it  may  be — oedema  of  the  glottis,  and  so  endan- 
gering life. 

2.  Hsematemesis,  or  vomiting  of  blood,  is  occasionally  observed. 
It  may  be  profuse  and  so  prove  fatal.  In  these  cases  the  rash  on 
the  skin  is  unusually  abundant  and  dark. 

3.  Diarrhoea  is  sometimes  so  severe  as  to  constitute  a  complica- 
tion.    In  some  epidemics  it  is  more  common  than  in  others. 

4.  Dysentery  complicates  typhus  in  camps  and  sieges.  It  pre- 
vailed also  in  some  of  the  Irish  epidemics  of  typhus.  The  poisons 
of  the  two  diseases  are,  doubtless,  developed  under  somewhat  similar 
circumstances. 

5.  Intestinal  haemorrhage  is  very  rare  but  very  fatal  in  typhus. 
It  is  due  to  a  liquefied  state  of  the  blood,  and  is  often  associated 
with  haematemesis  and  other  haemorrhages.  Its  aetiology,  therefore, 
is  different  from  that  of  intestinal  bleeding  in  typhoid. 

6.  Jaundice  also  is  rare  but  fatal  in  typhus.  Sir  William 
Jenner  never  met  with  an  instance,  but  15  cases  came  under  Mur- 
chison's  notice.  In  3  of  these  the  jaundice  was  due  to  consecutive 
congestion  of  the  liver ;  in  a  fourth  case,  it  resulted  from  gastro- 
duodenal  catarrh.  In  the  remaining  11  cases,  of  which  9  proved 
fatal,  the  jaundice  co-existed  with  the  rash  and  was  evidently  due 
to  some  abnormal  state  of  the  blood,  as  in  pyaemia,  yellow  fever, 
snake-bite,  and  other  blood-poisonings.  Bile  pigment  was  present 
in  the  urine,  so  there  was  true  jaundice. 

7.  Peritonitis  is  almost  unknown  as  a  complication  of  typhus. 
Sir  William  Jenner  and  Dr.  Alexander  Collie  have  each  recorded 
a  single  instance  of  the  occurrence  of  acute  idiopathic  peritonitis 
in  convalescence.  Murchison  saw  two  cases — the  causes  being, 
respectively,  the  bursting  of  a  softened  embolic  infarct  in  the 
spleen  and  tuberculosis  of  the  peritoneum. 

U 


290  TYPHUS   FEVER. 

V.  Diseases  of  the  "Urinary  Organs. — 

1.  Nephritis — whether  primary  or  secondary,  acute  or  chronic, 
is  a  most  serious  complication  of  typhus — often  inducing  uraeraic 
convulsions. 

2.  Catarrh  of  the  Bladder  (Cystitis)  sometimes  occurs  in  con- 
valescence, especially  after  retention  of  urine  and  over-distension 
of  the  bladder. 

3.  Hematuria  may  result  from : — (1.)  acute  haemophilia,  (2.) 
nephritis  or  congestion  of  the  kidneys,  (3.)  cystitis. 

VI.  Diseases  of  the  Integuments  and  Bones. — 

1.  (Edema,  if  slight,  is  generally  the  result  of  debility.  General 
anasarca  may  occur  from  nephritis.  Both  appear  in  convalescence, 
when  the  patient  begins  to  walk.  In  this  stage,  also,  I  have 
repeatedly  witnessed  extreme  suffering  from  painful  feet — the 
cause  apparently  being  non-removal  of  the  epithelium  from  the 
soles  of  the  feet,  and  consequent  obstruction  of  the  sweat  ducts. 

2.  Bedsores  (gangrene  of  the  integument)  occur  in  protracted 
cases  from  : — (1)  pressure,  as  over  the  sacrum,  trochanters,  heels, 
occiput,  ears,  elbows,  and  so  on;  (2)  early  neglect  and  want  of 
skilled  nursing ;  (3)  impaired  innervation. 

3.  Spontaneous  gangrene,  independently  of  pressure,  is  probably 
brought  about  by  arterial  thrombosis.  It  affects  the  toes  and  feet, 
the  nose,  penis,  scrotum,  and  pudenda  in  the  female.  It  occurs 
in  badly-fed  patients,  and  is  ushered  in  by  severe  shooting  pains, 
numbness,  coldness,  and  lividity.  In  my  "Medical  Report"  of 
Cork-street  Fever  Hospital,  for  the  year  ending  March  31,  1879, 
I  mentioned  the  case  of  a  typhus  patient  who  died  on  the  fourth 
day  of  the  fever  from  gangrene  from  the  fingers. 

4.  Noma,  or  Cancrum  Oris  (gangrenous  stomatitis),  is  a  very 
destructive  and  fatal  variety  of  gangrene,  which  attacks  the  cheek, 
mouth,  tongue,  and  face  of  delicate,  badly-fed  children,  about  the 
end  of  the  second  week  of  typhus.  It  is  not  peculiar  to  this 
disease,  for  it  occurs  also  in  smallpox,  scarlatina,  and  measles. 
According  to  Rilliet  and  Barthez,  not  more  than  one  in  twenty 
cases  of  noma  recover.  It  is  regarded  by  Hutchinson  as  allied  to, 
or  identical  with,  "hospital  gangrene."     The  first  sign  is  usually 


TYPHUS   FEVER.  201 

a  brawny  swelling  in  the  substance  of  the  cheek.  This  becomes 
purple,  softens  and  breaks  down,  and  then  the  gangrenous  ulcera- 
tion may  spread  in  all  directions,  causing  perforation  of  the  cheek, 
and  involving  the  lips,  tongue,  alse  nasi,  and  eyelids,  and  even 
causing  exfoliation  of  the  teeth  and  jaws.  I  have  myself  seen  two 
cases  of  this  terrible  complication.  In  one,  a  large  gaping  cavity 
opened  through  the  cheek  into  the  mouth,  and  the  smell  of  the 
breath  was  indescribably  foetid. 

5.  Hospital  Gangrene  attacks  wounds  and  ulcerated  surfaces  in 
persons  under  the  influence  of  typhus.  It  is  a  contagious  form  of 
gangrenous  inflammation  which  attacks  a  raw  surface,  and  is 
identical  with,  or  closely  allied  to,  acute  sloughing  phagedena. 
The  wound,  on  invasion,  ceases  to  discharge  and  becomes  coated 
with  a  gray  tenacious  slough  extending  from  the  centre  towards 
the  margin.  The  patient  usually  sinks  exhausted.  The  disease  is 
micro -parasitic,  and  its  ultimate  extinction  may,  therefore,  be 
looked  for  in  time. 

6.  Inflammatory  Swellings  or  Buboes  are  not  infrequent  in 
typhus,  especially  in  the  parotid  and  submaxillary  regions,  about, 
or  after  the  time  of  crisis.  They  form  rapidly,  and  are  very 
painful.  According  to  Drs.  Craigiea  and  Graves,b  the  inflamma- 
tion has  its  seat  mainly  in  the  subcutaneous  areolar  tissue,  and  not 
in  the  substance  of  the  glands.  In  some  cases,  they  have  seemed 
to  Murchison  to  originate  in  extravasations  of  blood.  The  same 
author  considers  that  these  inflammatory  swellings  constitute  a  con- 
necting link  between  typhus  and  Oriental  plague,  or  bubonic  fever. 
He  goes  so  far  as  to  say  that  "  typhus  is  probably  the  plague  of 
modern  times." 

These  bubonic  swellings  may  terminate  in  purulent  infiltration 
and  abscess,  or  may  recede  without  suppurating.  In  the  former 
case  especially  they  are  a  formidable  complication  of  typhus. 

VII.  Other  Specific  Diseases. — 

1.  Variola;  2.  Scarlet  Fever;  3.  Diphtheria ;  4.  Erysipelas; 

a  Fevers.     Edinburgh.     1837.     P.  301. 

b  Clinical  Lectures  on  the  Practice  of  Medicine.  New  Syd.  Soc.  1886. 
Vol.  I.,  page  223. 


292  TYPHUS   FEVER. 

5.  Typhoid  or  Enteric  Fever — are  all  known  to  have  complicated 
or  closely  followed  upon  typhus. 

Murchison  reports  the  case  of  a  girl  aged  fifteen,  ill  of  varioloid, 
who  was  conveyed  to  the  Smallpox  Hospital  in  a  carriage  used  for 
the  removal  of  typhus  patients.  While  still  going  through  her 
illness  a  typhus  rash  appeared.  In  18G2,  Dr.  Peacock  reported 
in  the  Lancet  a  case  in  which  the  rashes  of  typhus  and  scarlatina 
actually  co-existed.  Both  Murchison  and  W.  T.  Gairduer,  of 
Glasgow,  have  seen  typhus  complicated  with,  or  followed  by,  diph- 
theria. Erysipelas  of  the  face  is,  according  to  the  former  author, 
an  occasional  complication  of  typhus,  appearing,  perhaps,  as  early 
as  the  third  day,  but  more  commonly  towards  the  close  of  the 
second  week,  or  during  convalescence.  It  was  noticed  by 
Murchison,  in  92  out  of  14,676  cases,  or  once  in  159  cases. 
Lastly,  the  co-existence  of  typhus  and  typhoid  fevers  admits  of  no 
question,  and,  in  my  opinion,  the  frequency  of  this  accident  led  to 
the  confounding  of  these  two  fevers  and  to  the  view  that  they 
were  to  be  regarded  as  merely  modified  forms  of  the  one  essential 
disease. 


293 


CHAPTER  XXX. 
Typhus — (continued). 

Varieties  op  Typhus  :  Inflammatory,  nervous  or  ataxic,  adynamic,  ataxo- 
adynamic  or  congestive,  Typhus  siderans,  Typhus  levissimtts,  abortive,  catarrhal. 
Diagnosis  :  from  relapsing  fever,  enteric  fever,  "  jungle  fever,"  purpura, 
measles,  meningitis,  delirium  tremens,  asthenic  or  "  typhoid "  pneumonia, 
uraemia — Prognosis  and  Mortality  :  Bad  signs  in  typhus  ;  death-rate  influ- 
enced by  age,  sex,  condition  of  life  and  habits,  season,  pregnancy,  fatigue,  priva- 
tion, late  treatment — Pathological  Lesionb  :  (1)  General;  (2)  Special, 
affecting  the  integumentary,  respiratory,  circulatory,  nervous  and  digestive 
systems  of  the  body — Pathology  of  the  "  Typhoid  State." 

Varieties  of  Typhus. — The  following,  among  many  other 
varieties  of  this  fever,  have  been  described : — 

1 .  Inflammatory  Typhus,  characterised  by  much  febrile  reaction 
in  the  young  and  robust,  and  in  patients  of  the  upper  class — a  rare 
form,  having  occurred  in  only  40  out  of  1,302  cases  observed  by 
Barrallier. 

2.  Nervous  or  Ataxic  Typhus,  in  which  nervous  symptoms  pre- 
dominate. The  eruption  is  generally  copious,  dark,  and  petechial. 
This  form  is  also  described  under  the  names,  "  Typhus  Comatosus  " 
and  "Brain  Fever."  It  was  observed  by  Barrallier  in  109  out  of 
1,302  cases. 

3.  Adynamic  Typhus,  accompanied  by  great  muscular  and 
cardiac  prostration,  involuntary  evacuations,  and  a  tendency  to 
collapse.  The  skin  may  be  cool  and  the  pulse  slow.  Barrallier 
noted  this  form  in  92  out  of  his  1,302  cases. 

4.  Ataxo-adynamic  Typhus,  or  the  Congestive  Typhus  of 
Armstrong.  This  is  a  combination  of  the  ataxic  and  adynamic 
forms,  and  is  by  far  the  most  common  variety,  having  occurred  in 
810  out  of  Barrallier's  1,302  cases. 

Typhus  Siderans,  or  "  Blasting  Typhus,"  very  acute,  and  fatal 
within  a  few  hours  or  days. 


204  TYPHUS   FEVER. 

6.  Typhus  Levissimus,  or  "Mild  Typhus,"  observed  by 
Barrallier  in  235  out  of  1,302  cases.  "  Typhus  levissimus  "  was 
described  by  von  Hildenbrand  in  1810  under  this  name. 

7.  Abortive  Typhus.  Jacquot  gave  the  name  "  Typhisation  a 
petite  dose  "  to  cases  in  which  symptoms  occurred  in  persons 
exposed  to  infection  without  developing  into  actual  typhus.  Of 
this  incomplete  form  Niemeyer  observed  some  cases  in  the  Magde- 
burg Hospital,  and  a  large  number  of  observations  made  in  the 
Prague  epidemics  of  1843  and  1848  exactly  correspond  with  his. 
The  patients — who,  in  his  cases,  had  always  been  exposed  to  typhus 
poison — complained  of  rigors,  great  depression,  lightness  of  the  head, 
frontal  headache,  weakness  of  the  limbs,  loss  of  appetite,  and  other 
symptoms  common  to  the  incubation  stage  of  typhus,  renewed  and 
stronger  chills,  slight  delirium,  and  catarrhal  symptoms.  Towards 
the  close  of  the  first  week,  the  constitutional  disturbance,  fever,  and 
catarrhal  symptoms  disappeared,  and  the  patients  began  to  con- 
valesce. They  recovered  very  slowly,  suffering  much  from  prostra- 
tion. Niemeyer  called  the  affection  kt  a  rarely-mentioned  abortive 
form  of  typhus."  a 

8.  Catarrhal  Typhus,  an  Irish  appellation  for  the  disease,  because 
it  is  so  often  complicated  with  bronchial  catarrh.  In  Germany, 
the  names  "Broncho-typhus"  and  " Pneumo-typhus "  were  intro- 
duced by  Rokitansky,  as  already  mentioned. 

Diagnosis. — The  rash  is  pathognomonic  of  typhus.  Before  it 
appears,  we  have  grounds  for  a  differential  diagnosis  in  a  history 
of  exposure  to  the  infection,  of  such  symptoms  after  exposure  as 
rheumatoid  pains,  headache,  and  early  prostration. 

It  may  be  necessary  to  distinguish  typhus  from  the  following 
diseases,  or  diseased  conditions,  or  vice  versa  : — 

1.  Spirillum  Fever  (Relapsing  Fever). 

2.  Typhoid  or  Enteric  Fever. 

3.  Tropical  Remittent  Fever  ("  Jungle  Fever  "). 

4.  Purpura. 

5.  Measles. 

a  Text-Book  of  Clinical  Medicine.  Revised  Edition.  1880.  Vol.  II.,  page 
622. 


TYPHUS   FEVER.  2'J5 

6.  Meningitis  :   Encephalitis. 

7.  Delirium  Tremens. 

8.  Asthenic,  or  Typhoid,  Pneumonia. 

9.  Uraemia. 

1  &  2.  It  will  be  convenient  to  postpone  the  diagnosis  of  Typhus 
from  Relapsing  Fever  and  Typhoid  or  Enteric  Fever  until  those 
fevers  have  been  described. 

3.  The  "  Typhoid-Remittent "  Fever  of  the  tropics — or  "  Per- 
nicious Malarial  Fever"  (Hirsch) — commonly  called  "Jungle- 
Fever  "  in  India — is  a  miasmatic  disease,  caused  by  malaria.  It  is 
non-contagious,  independent  of  overcrowding,  prevails  in  tropical 
climates,  and  in  warm  and  rainy  seasons.  The  spleen  is  much 
enlarged,  and  quinine  often  acts  specifically.  Petechias  may  be 
present,  but  the  macular  rash  of  typhus  is  wanting. 

4.  Riverius  long  ago  (1648)  distinguished  the  petechia  sine  febre 
(purpura)  from  typhus  (febris  petechialis). 

Purpura  is  non-contagious ;  as  a  rule,  apyrexial ;  is  unaccom- 
panied by  cerebral  symptoms,  but  is  attended  with  haemorrhages 
from  the  mucous  membranes.  The  spots,  too,  are  larger  than  the 
petechias  of  typhus. 

5.  Measles  is  distinguished  from  typhus  by  the  history  of  ex- 
posure to  the  poison  of  measles,  the  prevalence  of  an  epidemic, 
the  prodromal  catarrhal  symptoms,  the  brighter  tint  and  greater 
abundance  of  its  rash,  the  presence  often  of  diarrhoea,  and  the 
early  defervescence.  The  bronchial  catarrh  of  typhus  appears  late 
and  in  the  lighter  cases  the  rash  is  not  abundant. 

6.  In  Inflammation  of  the  Brain  (Cerebritis,  or  Encephalitis) 
or  its  membranes  (Meningitis),  delirium  is  present  from  the  very 
first,  and  is  accompanied  by  excruciating  headache.  The  senses 
are  morbidly  acute,  whereas  they  are  dull  and  blunted  in  typhus. 
The  pulse  is  bounding.  The  eyes  have  not  the  heavy,  dull  look  of 
typhus,  nor  is  the  rash  of  that  disease  present.  Loud  cries  and 
screams  (cri  cerebral),  as  well  as  strabismus,  ptosis,  opisthotonos, 
and  partial  palsy,  characterise  meningitis.  There  is  extreme  in- 
tolerance of  light  (photophobia)  and  of  sound.    Nausea  and  vomiting 


296  TYPHUS   FEVER. 

are  common.     A  red  streak  is  left  upon  the  skin  after  pressure  by 
the  finger  (tache  cere'brale,  or  cerebral  stain). 

7.  The  Delirium  Tremens  of  the  drunkard  differs  from  that  of 
typhus  in  setting  in  with  sleeplessness  and  delirium,  without 
shivering,  headache,  or  pains  in  the  limbs.  The  tongue  is  moist 
and  coated  with  a  creamy  fur,  the  skin  is  moist  and  cool,  there  is 
no  eruption,  and  the  temperature  is  not  high. 

8.  In  Asthenic  or  Typhoid  Pneumonia  the  apex  of  the  lung  may 
be  chiefly  affected,  when  the  symptoms  of  the  local  disease  may  be 
masked  by  the  constitutional  state  (latent  pneumonia).  The  differ- 
ential diagnosis  will,  under  such  circumstances,  turn  on  the  presence 
of  physical  signs  in  the  lung  and  the  absence  of  eruption. 

9.  In  Uraemia  from  chronic  renal  disease,  the  "  typhoid  state" 
may  be  fully  developed,  leading  to  great  difficulty  in  diagnosis. 
But  it  is  in  chronic  interstitial  nephritis  (contracted  granular 
kidney — renal  cirrhosis)  that  uraemia  chiefly  occurs.  This  form 
of  kidney  disease  usually  occurs  in  advanced  life,  especially  in 
gouty  subjects  or  persons  suffering  under  chronic  lead-poisoning 
(plumbism),  and  the  temperature  is  normal  or  subnormal.  This 
last  circumstance  Murchison  calls  "the  grand  point  of  distinction." 
Finally,  the  typhus  rash  is,  of  course,  wanting  in  uraemia. 

Prognosis  and  Mortality. — 

The  unfavourable  signs  in  a  given  case  of  typhus  are : —  (1)  A 
presentiment  of  death,  often  entertained  by  physicians  when  ill  of 
typhus ;  (2)  a  soft  and  compressible  pulse  in  rate  above  120  in  an 
adult ;  (3)  absence  of  cardiac  impulse,  and  lessened  or  silent  first 
sound  of  the  heart ;  (4)  hurried  respirations,  particularly  if  no 
pulmonary  lesion  exists  to  explain  this  symptom  ;  (5)  sleeplessness 
and  delirium ;  (6)  complete  coma-vigil  of  Sir  William  Jenner ; 
(7)  the  presence  of  the  pin-hole  pupil  of  Graves ;  (8.)  great  pros- 
tration; (9)  convulsions;  (10)  muscular  tremors  and  hiccough; 
(11)  relaxation  of  the  sphincters  before  the  tenth  day;  (12)  tym- 
panites or  meteorism ;  (13)  lividity  of  the  face  and  surface  gene- 
rally;  ^14)  abundance  and  darkness  of  the  rash;  (15)  persistent 
high  temperature  ;  (16)  profuse  sweating  after  the  tenth  or  twelfth 
clay;  (17)  the  presence  of  any  serious  complication. 


TYPHUS    FEVER.  297 

When  death  takes  place,  it  occurs  from  asthenia,  with  heart- 
failure  ;  or  from  ataxia,  nervous  symptoms  deepening  into  coma ; 
or  from  some  intercurrent  complication  or  sequela. 

Mortality. — There  is  reason  to  believe  that  the  death-rate  from 
typhus  among  the  community  taken  all  round  does  not  exceed  10 
per  cent,  of  those  attacked.  Hospital  statistics  show  a  much 
higher  rate.  Thus,  in  23  years  ending  with  1870,  of  18,268  patients 
admitted  in  typhus  to  the  London  Fever  Hospital,  3,457  died,  giving 
a  mortality  of  18*92  per  cent.  The  mortality  since  1862  has  been 
less  than  it  had  been  previously — 18*22  per  cent,  compared  with 
20*89  per  cent.  As  in  the  case  of  other  epidemic  diseases,  the 
mortality  is  greater  immediately  after  the  outbreak  than  in  the 
later  stages. 

The  last  serious  epidemic  in  the  Annals  of  Cork-street  Fever 
Hospital  occurred  in  the  years  1880-82,  immediately  in  the  wake 
of  the  smallpox  scourge  of  the  years  1876-80.  So  far  back  as 
January,  1880,  typhus  showed  an  epidemic  tendency  in  Dublin, 
the  female  department  of  the  North  Dublin  Union  Workhouse 
being  the  chief  focus  from  which  the  disease  spread  in  the  first 
instance.  Out  of  57  cases  of  typhus  admitted  to  Cork-street  Fever 
Hospital  in  the  three  months  ending  March  31,  1880,  not  fewer 
than  40  came  from  the  female  division  of  the  North  Dublin  Union. 
The  outbreak  attained  its  greatest  violence  in  the  last  quarter  of 
1880,  during  which  the  admissions  rose  to  217.  It  finally  died 
out  in  the  early  part  of  1882,  the  admissions  falling  to  28  in  the 
first  three  months  of  that  year.  In  all,  675  patients  were  treated 
during  the  epidemic,  and  of  these  71  died,  the  resulting  death-rate 
being  10*5  per  cent.  As  usual,  the  disease  was  much  more  malig- 
nant at  the  beginning  of  the  epidemic  than  it  was  in  its  later  stages. 
It  is  interesting  to  recall  the  fact  that  this — the  last  serious  out- 
break of  typhus  in  Dublin — followed  not  only  in  the  wake  of  a 
prolonged  epidemic  of  smallpox,  but  also  in  that  of  the  disastrous 
year  1879,  the  continuous  cold  and  wet  of  which  led  to  unparalleled 
and  general  distress  throughout  Ireland. 

With  the  assistance  of  Dr.  John  Marshall  Day,  the  Resident 
Medical  Officer  of  Cork  street  Fever  Hospital,  I  have  tabulated  the 


298  TYPHUS    FEVER. 

number  of  cases  of  typhus  admitted  to  the  hospital  annually  in  the 
twenty  years  ending  March  31,  1891,  as  well  as  the  deaths  from 
this  fever  which  occurred  in  each  of  the  same  twenty  years.  I  find 
that  the  total  number  of  cases  admitted  was  2,895,  of  which  363 
proved  fatal.  These  figures  give  an  average  mortality  of  12*6  per 
cent.,  or  nearly  one  in  eight.  It  is  worthy  of  note  that  the  wards  of 
Cork-street  Hospital  are  splendidly  ventilated — indeed  almost  to 
excess  in  winter.  I  have  no  doubt  that  this  free  ventilation 
contributes  largely  to  so  low  a  death-rate  from  typhus. 

Age  influences  the  mortality  from  typhus  in  a  most  remarkable 
way.  This  is  shown  in  the  accompanying  Diagram  (B.j,  copied  from 
Murchison's  "Treatise  on  the  Continued  Fevers  of  Great  Britain," 
by  permission  of  Messrs.  Longmans,  Green  &  Co.  It  shows  the 
variations — according  to  age~of  the  percentage  death-rate  of  18,132 
cases  of  typhus  admitted  to  the  London  Fever  Hospital.  Accord- 
ing to  this  diagram,  the  mortality  during  the  first  five  years  of 
life  was  6-69  per  cent.;  in  the  second  lustrum,  it  fell  to  3*59  ; 
between  10  and  15  it  was  only  2-28  per  cent.,  between  15  and  20 
it  rose  to  4*46  per  cent.  After  20,  it  progressively  increased  until 
of  those — 

Above  30  years  of  age  35*39  per  cent.  died. 


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And  yet  typhus  is  not  invariably  fatal  in  advanced  life.  The  fol- 
lowing is  quoted  from  the  "  Medical  Report  of  Cork-street  Fever 
Hospital,"  for  the  years  1820-21,  written  by  Dr.  William  Stoker, 
grandfather  of  Mr.  William  Stoker,  now  one  of  the  Professors  of 
Surgery  in  the  Royal  College  of  Surgeons  in  Ireland  : — "  A  very 
remarkable  case  of  malignant  typhus  fever  passed  through  the 
wards  under  my  care  in  the  month  of  January  (1821).  It  was 
that  of  a  man  of  the  name  of  Owens,  104  years  of  age,  husband  to 
the  woman  of  that  name,  whose  death  is  given  in  the  foregoing 
tabular  obituary.     This  man's  fever  continued  for  three  weeks, 


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TYPHUS    FEVER.  209 

through  a  greater  part  of  which  time  he  was  delirious,  his  limbs 
tremulous,  his  body  covered  with  petechia?,  and  his  extremities 
livid.  The  crisis  of  his  illness  was  sudden  and  decisive,  and  his 
convalescence  rapid  ;  so  that  in  a  few  days  afterwards  he  was 
able  to  walk  to  the  House  of  Recovery,  whence  he  was  dis- 
missed in  as  perfect  health  as  was  compatible  with  his  time  of  life 
within  a  week  from  the  commencement  of  his  convalescence." 

Sex. — Men  die  of  typhus  in  greater  numbers  than  women,  per- 
haps, because  the  average  age  of  male  typhus  patients  is  greater 
than  that  of  the  females,  but  more  probably,  because  men  are 
more  muscular  as  well  as  more  intemperate.  Disintegration  of 
tissue  by  the  fever  process  would,  under  these  circumstances,  go 
on  more  rapidly  in  men  than  in  women,  while  elimination  would 
be  checked,  owing  to  the  morbid  changes  in  the  liver  and  kidneys, 
brought  about  by  alcoholism. 

The  intemperate,  the  sickly,  the  obese,  or  the  very  muscular, 
the  hard-worked,  whether  bodily,  or  mentally,  but  especially  the 
latter,  run  the  worst  chance  if  attacked  by  typhus. 

As  regards  months  and  seasons,  the  mortality  from  typhus  drops 
to  a  minimum  as  summer  advances,  and  rises  to  a  maximum  in  the 
late  winter  and  spring.  During  twenty-three  years  (1848-1870), 
the  mortality  at  the  London  Fever  Hospital  was  considerably  less 
(16 "2  per  cent.)  in  the  last  five  than  in  the  first  seven  months  of  the 
year  (20*7  per  cent.).  This  is,  no  doubt,  the  result  of  increased 
destitution,  overcrowding,  and  defective  ventilation  in  winter  on 
the  one  hand,  and  of  plenty  and  a  more  open-air  life  in  summer  on 
the  other. 

Pregnancy  adds  little  to  the  danger  of  typhus,  but  suckling 
induces  anaemia  and  increases  the  chances  of  death  by  asthenia. 
Fatigue  and  privation  greatly  increase  the  mortality  from  this 
fever,  and  so  does  neglect  of  treatment  in  the  early  stages.  Lastly, 
too  late  removal  to  hospital  is  most  prejudicial.  This  was  insisted 
upon  by  Dr.  Alison,  of  Edinburgh,  in  1844  and  1849,  and  I  have 
had  repeated  opportunities  of  verifying  the  correctness  of  his  obser- 
vations. 

In  the  year  ending  March  31,  1884,  fifteen  deaths  occurred  in 


300  TYPHUS    FEVER. 

Cork-street  Fever  Hospital  before  the  deceased  patients  had  been 
forty-eight  hours  under  treatment  in  the  hospital.  Six  out  of  these 
fifteen  cases  were  suffering  from  typhus.  "  Dying  on  admission  " 
is  a  grave  indictment  against  those  who  were  responsible  for  the 
removal  of  the  unhappy  sick  to  hospital  in  their  last  hours.  On 
July  5,  1882,  I  drew  the  attention  of  the  Managing  Committee  of 
Cork-street  Hospital  to  the  circumstances  under  which  the  first 
death  which  occurred  in  the  hospital  within  the  official  year, 
beginning  on  April  1,  had  taken  place.  On  the  afternoon  of  July 
1,  a  married  woman,  aged  forty,  was  sent  in  on  the  fifteenth  day  of 
bad  petechial  typhus  with  bed-sores,  and  in  an  extremely  prostrate 
condition.  She  lived  for  four  and  a  half  days  after  admission.  At 
the  time,  I  expressed  the  opinion  that  a  patient,  of  middle  age  also, 
so  far  advanced  in  typhus  of  a  severe  type,  could  not  be  safely 
moved  to  hospital,  and  should  have  been  treated  and  nursed  at 
home.  On  August  7,  1883,  I  again  called  the  attention  of  the 
Committee  of  the  Hospital  to  a  very  similar  case.  A  married 
woman,  aged  forty- nine,  was  sent  in  on  the  tenth  day  of  severe 
typhus,  during  a  violent  thunder-storm.  She  died  twenty-four  hours 
after  admission.  Can  anything  more  deplorable  be  imagined  than 
the  want  of  judgment  exhibited  in  this  and  other  "  cases  sent  in 
when  beyond  recovery  ?  " 

Pathological  Lesions. — Cadaveric  rigidity  is  of  short  duration 
in  typhus,  and  putrefaction  takes  place  rapidly.  Emaciation  is 
considerable,  but  much  less  than  in  typhoid  fever.  Speaking  of  the 
anatomical  lesions  met  with  in  fatal  cases  of  typhus  fever, 
Murchison  says  that  the  patient  usually  dies  before  the  body  has 
had  time  to  become  much  emaciated.  Dr.  Cayley,  however,  quotes 
Dr.  Hermann,  of  the  Obuchow  Hospital,  St.  Petersburg,  to  prove 
that  a  considerable  loss  of  weight  takes  place  during  an  attack  of 
typhus.  That  physician  found  that  the  average  daily  loss  of  weight 
ranged  from  £  lb.  to  3  lbs.  The  greatest  total  loss  was  31  lbs.  A 
widespread  congestion  (passive  hyperemia)  is  the  most  constant 
and  noticeable  post-mortem  appearance  in  typhus. 

In  connection  with  the  several  systems  of  the  body,  the  following 
additional  pathological  appearances  may  present  themselves  : — 


TYPHUS    FEVER.  301 

1.  The  Integumentary  System. — The  petechia;  of  typhus  remain 
visible  after  death.  Bedsores  may  occasionally  be  observed,  and 
less  frequently  spontaneous  gangrene.  Rarely,  lymphatic  and 
bubonic  swellings  may  be  present.  There  is  much  livid  discolora- 
tion of  the  surface,  and  the  green  tinge  of  decomposition  sets  in 
very  early  after  death. 

2.  The  Respiratory  System. — The  chief  features  are  traces  of  a 
widespread  catarrhal  inflammation  of  the  air  passages  (catarrhal 
laryngitis,  tracheitis,  and  bronchitis),  hypostatic  consolidations  in 
the  lungs,  rarely  pneumonic  consolidations,  and  pleuritis  with 
purulent  effusion. 

3.  The  Circulatory  System. — The  blood  is  profoundly  altered, 
being  feebly  coagulable,  often  staining  the  endocardium  and  the 
intima  vasorum.  Leberta  says  that  the  blood  found  in  the  heart 
and  larger  veins  usually  forms  a  black  pultaceous,  soft  clot,  in  which 
there  is  but  little  distinctly  coagulated  fibrin.  Examined  under 
the  microscope,  rouleaux  are  found  wanting,  and  the  red  blood- 
corpuscles  are  crenated  and  misshapen.  The  muscular  tissue  of 
the  heart  is  softened  and  friable.  Rokitansky b  held  that  this 
softening  was  "  a  simple  diminution  of  consistence,  not  depending 
upon  any  disturbance  of  texture."  But  cloudy  swelling  and  granular 
fatty  degeneration  have  been  observed  by  all  modern  pathologists. 
The  appearances  have  been  already  described  (see  Chapter  XV1IL, 
page  178). 

4.  The  Nervous  System. — The  membranes  of  the  brain  are 
highly  vascular,  but  this  is  not  to  be  regarded  as  a  token  of  in- 
flammation— the  congestion  is,  in  fact,  passive  or  mechanical,  and 
depends  on  heart-failure  or  pulmonary  obstruction.  In  rare  in- 
stances deposits  of  lymph  or  pus,  no  doubt,  indicate  the  presence  of 
recent  inflammation.  Murchison,  Stokes,  and  other  authorities 
rightly  hold  that  no  relation  exists  between  the  vascularity  of  the  cere- 
bral membranes  and  the  cerebral  symptoms  observed  during  life. 

"  The  assumption  of  inflammation  of  the  brain  in  the  presence  of 

a  Von  Ziemssen's  Cyclopaedia  of  the  Practice  of  Medicine.  Art.  "  Typhus 
Fever."     Vol.  I.,  page  335. 

b  Pathological  Anatomy.     Sydenham  Society.     1852.     Vol.  IV.,  page  171. 


302  TYPHUS   FEVER. 

violent  nervous  symptoms  in  fever,"  wrote  Dr.  Stokes,a  "  consti- 
tutes one  of  the  greatest  dangers  to  which  young  physicians  are 
exposed,  when  they  come  to  deal  with  the  most  formidable  com- 
plication of  the  disease — aye,  and  old  physicians,  too,  whose  clinical 
education  has  been  imperfect.  I  have  known  of  the  application  of 
leeches  to  the  head  in  an  advanced  case  of  cerebral  fever  with 
delirium  ferox  to  be  followed  by  sudden  sinking  and  death." 

Increased  effusion  of  serum  within  the  cranium  is,  according  to 
Murchison,  one  of  the  most  frequent  morbid  appearances  in  typhus. 
The  most  common  seats  of  this  effusion  are  beneath  the  arachnoid 
and  in  the  lateral  ventricles,  and  sometimes  in  the  cavity  of  the 
arachnoid.  The  serum  is  transparent  or  sometimes  apparently 
opalescent,  owing  to  slight  opacity  of  the  superposed  membrane. 
It  may  be  colourless  or  straw-coloured.  It  does  not  contain  flakes 
of  lymph  or  exudation-corpuscles. 

There  is  no  relation  between  the  amount  of  effusion  and  the  in- 
tensity of  the  symptoms  of  brain  trouble,  nor  is  the  increased 
serosity  a  sign  of  inflammation.  Murchison  thinks  that  in  typhus 
the  brain  wastes  from  malnutrition  and  the  effusion  takes  place  to 
fill  up  space.  It  would  be  more  correct  to  say  that  from  the  con- 
gested vessels,  with  badly-nourished  walls,  and  owing  to  lessened 
pressure  upon  them  by  the  shrunken  brain,  effusion  takes  place. 

The  cerebrum  and  cerebellum  are  generally  healthy.  They 
may  be  highly  vascular,  a  condition  shown  by  diminished  consis- 
tence, a  darker  tint  of  the  grey  matter,  and  numerous  blood-points 
on  section  of  the  white  matter.  Softening  of  the  brain  has  been 
occasionally  observed,  and  Barrallier  b  has  called  attention  to  a  re- 
markable indistinctness  of  the  arbor  vita;  of  the  cerebellum  in  some 
cases. 

Similar  appearances  to  those  described  in  connection  with  the 
brain  are  less  frequently  seen  in  the  spinal  cord. 

Nothing  definite  has  yet  been  ascertained  as  to  the  condition  of 
the  sympathetic  system  of  nerves  in  typhus.  Marmy  found  many 
of  the  ganglia  softened,  and  Beveridge  found  the  cervical  ganglia 

a  Lectures  on  Fever.     London  :  Longmans,  Green  &  Co.     1874.     Page  279. 
b  Du  Typhus  epidemique  a  Toulon.     Paris.     1861.     Page  106. 


TYPHUS   FEVER.  303 

enlarged  and  dense  from  the  deposit  of  an   amorphous  granular 
matter. 

5.  The  abdominal  viscera. — The  characteristic  lesions  of  enteric 
fever  are  wanting.  The  kidneys  are  not  uncommonly  hyperaemic 
and  enlarged,  while  the  tubes  are  engorged  with  blood  and  stuffed 
with  granular  epithelium.  Acute  nephritis  is  thus  unmistakably 
present  in  not  a  few  instances. 

The  pathology  of  the  "  Typhoid  State  "  is  not  yet  clearly  made 
out.  Murchison  thinks  it  is  very  possible  that  the  condition  to 
which  this  name  is  given  may  have  a  common  origin  in  all  the 
diseases  in  which  it  shows  itself,  or  may  be  due  to  the  accumulation 
in  the  blood  of  the  products  of  disintegrated  tissue  as  the  result 
of  the  primary  malady.  The  connection  between  the  typhoid  state 
and  the  presence  of  urea,  carbonate  of  ammonia,  or  other  nitro- 
genous detritus  in  the  blood  is,  according  to  Murchison,  a  subject 
which  deserves  further  investigation. 

James  Andrew a  considers  that  the  chief  primary  cause  of  the 
condition  may  be  the  injurious  influence  of  a  high  internal  tem- 
perature upon  the  central  nervous  organs,  but  this  same  tempera- 
ture acts  directly  also  upon  the  parenchyma  of  glandular  organs, 
and  upon  the  muscular  fibre  both  of  the  heart  (Stokes)  and  of  the 
voluntary  muscles  (Zenker).  The  disorder  of  the  nervous  centres 
must  be  greatly  increased  by,  if  not  sometimes  decidedly  due  to, 
the  changes  in  the  composition  of  the  blood,  and  in  the  forces  of 
the  circulation. 

Murchison  admirably  sums  up  the  pathological  appearances  in 
typhus  as  follows  : — 

"  1.  There  is  no  lesion  constant  in,  or  peculiar  to,  typhus. 

"  2.  The  intestines  never  exhibit  the  peculiar  lesions  [almost] 
invariably  present  in  typhoid  fever,  and  the  mesenteric  glands  are 
not  enlarged. 

"3.  No  evidence  of  acute  inflammation  is  found  in  the  brain  or 
its  membranes,  to  account  for  the  cerebral  symptoms. 

"4.  The  chief  morbid  appearances  are:  a  fluid  condition  of  the 
a  Quain's  Dictionary  of  Meaicine.     1883.     Art.  "Typhoid  State." 


304  TYPHUS   FEVER, 

blood,  atrophy  of  the  brain,  with  increase  of  intra-cranial  8uid, 
granular  degeneration  of  the  sympathetic  nerves ;  atrophy,  with 
granular  or  waxy  degeneration  of  the  muscles  and  heart ;  enlarge- 
ment and  congestion  of  the  liver,  spleen,  pancreas,  and  kidneys, 
with  a  swollen,  granular  state  of  the  gland-cells  ;  bronchial  catarrh 
and  pulmonary  hypostasis.  The  relative  frequency  of  these  lesions 
varies  at  different  times  and  places ;  none  are  of  constant  occur- 
rence, or  peculiar  to  typhus." 


305 


CHAPTER  XXXI. 

The  Treatment  of  Typhus. 

Prophylactic  and  Curative  Treatment  (or  "  Management  ").  Preven- 
tive Measures  :  Personal  cleanliness,  good  food  and  air-space,  ventilation. 
Management  :  hygienic  measures  adopted  at  Cork-street  Fever  Hospital, 
Dublin.  Nursing.  Medicinal  treatment  must  be  purely  symptomatic.  Water 
Treatment.  Quinine.  Alcoholic  Stimulants.  Food. — Treatment  of  Compli- 
cations and  Sequels  :  Pulmonary  congestion,  bronchitis,  paresis,  incontinence 
of  urine,  convulsions,  bedsores,  phlegmasia  and  thrombosis,  oedema.  Con- 
valescence :  costive  bowels.     Tonics.     Change  of  Air. 

This  topic  has  already  been  dealt  with  in  detail  in  the  Chapters 
on  the  General  Principles  of  Treatment. 

"It  is  easier  to  prevent  Typhus  than  to  cure  it,"  said  Murchison, 
and  if  thorough  effect  could  be  given  to  all  the  preventive  measures 
described  in  Chapter  IV.,  typhus  fever  would,  in  all  probability, 
soon  cease  to  exist.  Nothing  is  more  striking  than  the  diminution 
of  this  fever  of  late  years — even  in  those  countries  (such  as 
Ireland),  and  towns  (such  as  Cork,  Dublin,  Glasgow,  and  Liver- 
pool), where  the  repeated  epidemics  in  the  past  caused  it  to  rank 
as  an  endemic  disease. 

In  the  recognition  of  the  facts  that  destitution,  overcrowding, 
and  deficient  ventilation,  enormously  predispose  to  typhus,  lies  the 
key  to  the  prophylaxis  of  the  disease.  Personal  cleanliness,  an 
abundant  supply  of  good,  wholesome,  food,  a  sufficient  cubical  air- 
space per  head  of  the  population  (500  cubic  feet,  at  least),  and  free 
ventilation,  which  means  the  supply  of  3,000  cubic  feet  of  fresh  air 
per  head  every  hour,  are  the  best  preventives. 

Those  sick  of  typhus  should  be  treated  in  large  airy  wards  or 
rooms — 1,500  to  2,000  cubic  feet  being  allowed  to  each  patient — - 
and  the  beds  should  be  at  least  six  feet  apart. 

We  have  already  seen  that,  if  a  single  fact  is  well  established  in 
the  life-history  of  the  contagium  of  typhus,  it  is  that  the  virus  is 
most  readily  destroyed  or  rendered  inert  by  contact  with  atmo- 

X 


306  TYPHUS  FEVER. 

spherical  air,  presumably  through  oxidation.  If  this  is  so,  what 
vast  magazines  of  typhus-poison  might  be  rendered  powerless 
for  mischief  in  every  gentle  breeze,  not  to  speak  of  a  more  violent 
tempest,  provided  only  doors  and  windows  are  not  too  closely 
barred. 

After  thus  referring  to  the  destruction  of  the  virus  of  typhus 
fever  by  oxidation,  through  the  natural  agency  of  the  currents  of 
the  atmosphere  and  of  strong  winds,  it  may  be  of  interest  to 
describe  the  therapeutical  means  adopted  by  my  colleagues  and 
myself  during  the  last  epidemic  in  Cork-street  Fever  Hospital,  with 
a  view  of  neutralising  the  fever  poison,  when  it  was  actually  at 
work  in  the  patient's  system. 

First,  attention  was  constantly  directed  to  the  ventilation  of  the 
fever  wards.  In  severe  cases,  where  the  eruption  was  copious  and 
dark  (petechial),  a  strong  current  of  fresh  air  was  allowed  to  blow 
over  and  around  the  patient  whenever  the  state  of  the  weather  at 
all  permitted  it. 

Lebert a  says  on  this  point  that  in  a  recent  epidemic  at  Breslau 
he  found  it  to  be  an  excellent  plan,  even  during  the  severest  cold 
of  winter,  to  keep  the  windows  open  during  part  of  the  day  and 
night.  The  patients  bore  it  well  so  long  as  the  fever  lasted, 
though  they  proved  very  sensitive  to  cold  after  the  defervescence. 

The  weight  of  bed-clothes  was  reduced  to  a  minimum,  so  that 
the  fresh  air  might  easily  reach  the  surface  of  the  whole  body. 
It  might  be  supposed  that  the  exposure  would  give  the  patients 
cold  ;  but  experience  proves  that  this  is  not  so,  and  I  am  convinced 
that  in  a  vast  majority  of  cases  the  bronchial  catarrh  and  other 
pulmonary  affections  of  typhus  are  not  the  result  of  cold,  but  of 
passive  hyperemia  of  the  bronchial  mucous  membrane  and  of  the 
parenchyma  of  the  lungs — that,  in  fact,  these  lesions  belong  to  the 
essential  pathology  of  the  disease. 

Secondly,  directions  were  given  to  the  nurses  in  all  bad  cases, 
with  profuse  eruption,  to  sponge  the  entire  surface  of  the  body 
twice  or  three  times  a  day  with  vinegar  and  warm  water. 

a  Art.  "Typhus  Fever,"  in  von  Ziemssen's  Cyclopaedia  of  the  Practice  of 
Medicine. 


TYPHUS    FEVER.  307 

Thirdly,  solution  or  tincture  of  the  perchloride  of  iron,  chlorate 
of  potassium  in  moderate  doses,  or  quinine,  was  given  in  nearly 
all  such  cases,  either  separately  or  in  combination,  and  with  re- 
markably good  results. 

Under  this  hygienic  treatment  several  very  grave  cases  pro- 
gressed favourably,  and  it  is  an  interesting  fact  connected  with  my 
own  practice  in  the  hospital,  that  I  seldom  felt  called  upon  to  order 
for  these  patients  any  large  quantity  of  alcoholic  stimulants. 

Bearing  in  mind  the  early  and  great  prostration  of  typhus,  the 
patient  should  take  to  bed  as  soon  as  possible  in  a  cheerful,  large, 
airy  apartment,  with  two  bedsteads  in  it — one  for  day  and  one  for 
night. 

The  best  form  of  bed  for  a  typhus  patient  is  a  hair-mattress 
laid  upon  a  woven-wire  spring  mattress.  The  bed-clothes  should 
be  light.  The  patients'  head  should  be  kept  as  cool  as  possible, 
but  his  feet  should  be  warm. 

There  is  no  disease  in  which  the  services  of  a  trained,  expe- 
rienced, strong,  and  judicious  nurse  are  more  needed  than  in  typhus. 
In  the  ninth  of  his  "  Clinical  Lectures  on  the  Practice  of  Medicine," 
Dr.  Graves  gives  excellent  advice  on  this  point.  He  says  : — "  You 
should  never,  if  possible,  undertake  the  treatment  of  a  case  of  fever 
where  the  friends  or  relations  of  the  patient  supply  the  place  of  a 
regular  fever  nurse.  The  mistaken  tenderness  of  relatives  and  their 
want  of  due  firmness,  presence  of  mind,  and  experience,  will 
frequently  counteract  your  exertions  and  mar  your  best  efforts. 
Affection  and  sorrow  cloud  the  judgment,  and  hence  it  is  that  very 
few  medical  men  ever  undertake  the  treatment  of  dangerous  illness 
in  the  members  of  their  own  families.  .  .  .  Again,  it  will  not  do 
to  have  a  nurse  who  has  been  usually  employed  in  other  diseases  ; 
your  assistant  must  be  a  regular  fever  nurse,  and  the  man  who 
undertakes  the  treatment  of  a  long  and  dangerous  case  of  fever 
without  such  an  assistant  will  often  have  cause  to  regret  it.  .  . 
A  fever  nurse  has  a  vast  deal  in  her  power ;  if  an  enema  is  to  be 
administered,  the  patient  will  be  much  less  disturbed  and  annoyed 
than  if  it  were  given  by  an  unskilful  person.  The  mere  handling 
of  a  patient — the  moving  of  him  from  one  bed  to  another — the 


308  TYPHUS    FEVER. 

simple  act  of  giving  him  medicine  and  drink — the  changing  of  his 
slieets  and  linen — the  dressing  of  his  blisters — and  a  thousand 
other  offices,  can  be  performed  with  advantage  only  by  an  ex- 
perienced nurse.  Always  bear  in  mind  that  it  is  of  the  utmost 
importance  to  economise  the  patient's  strength  in  fever.  The  very 
act  of  lifting  him  up,  or  removing  him  from  one  side  to  another, 
tends  to  produce  exhaustion.  In  the  advanced  stages  of  fever, 
the  services  of  a  properly  qualified  nurse  are  inestimable.  Then 
there  is  the  moral  management  of  the  patient,  and  this  is  an  office 
which  no  one  can  undertake  unless  qualified  by  experience,  and  a 
correct  knowledge  of  the  habits  of  persons  labouring  under  such 
forms  of  disease.  Everyone  admits  the  value  of  moral  superin- 
tendence in  the  treatment  of  the  insane.  Now  there  are  very  few 
patients  who  are  not  in  a  state  analogous  to  insanity,  for  a  longer 
or  shorter  period,  during  a  course  of  typhus  fever.  There  is  a 
necessity  for  moral  management  in  fever  as  well  as  in  insanity, 
and  this  is  understood  only  by  an  experienced  nurse." 

Both  in  hospital  and  private  practice,  the  nurse,  or  nurses — for 
there  should  be  a  day  nurse  and  a  night  nurse — should  keep  a 
written  record,  for  the  information  of  the  physician,  of  the  times 
at  which  food  and  stimulants  have  been  given,  the  bowels  have 
moved  or  water  has  been  passed;  of  the  changes  in  the  nature  and 
character  of  the  symptoms  from  visit  to  visit  of  the  physician ;  and 
of  the  behaviour  of  the  temperature  and  the  rate  of  the  pulse  and 
respirations  at  stated  intervals  already  agreed  on. 

So  far  as  the  physician  is  himself  concerned,  every  case  of  fever 
should  be  visited  at  least  twice  a  day — morning  and  evening — 
during  the  acute  and  critical  stages,  for  a  few  hours  may  mean  life 
or  death  to  the  sufferer. 

The  medicinal  treatment  of  typhus  is  purely  symptomatic,  for 
as  yet  we  possess  no  specific  for  this  disease,  if  we  except  fresh  air. 

"  Although,"  says  Murchison,  "  many  practitioners  have  at  diffe- 
rent times  proposed  to  cut  short  an  attack  of  typhus  by  such  heroic 
remedies  as  blood  letting,  the  cold  affusion,  emetics,  and  quinine, 
we  possess  as  yet  no  such  specific"  as  will  arrest  its  progress  or 
shorten  its  duration. 


TYPHUS    FEVER.  309 

Von  Hildenbrand,  early  in  the  nineteenth  century,  observed — 
"  No  method  yet  known,  whether  rational  or  empirical,  can  cure  the 
contagious  typhus,  either  in  a  direct  or  in  an  indirect  manner,  or 
even  abridge  its  ordinary  and  natural  course,  which  is  about  four- 
teen days." 

To  the  same  effect  Stokes  a  declared  that  "  the  treatment  of  fever, 
whether  it  be  typhus  or  typhoid,  is  reducible  to  a  simple  formula, 
and  is  essentially  the  same  in  both  types  of  disease.  We  know  of 
no  cure  for  fever;  no  man  has  ever  cured  it.  It  is,  however, 
curable  spontaneously.  If  you  leave  it  to  its  own  course,  it  is 
capable  of  curing  itself.  It  will  spontaneously  subside.  Remem- 
bering the  law  of  periodicity,  the  great  object  of  the  physician 
should  be  to  gain  time,  preserving  the  patient  from  the  dangers 
which  threaten  him,  which  belong  to  this  special  state  of  life.  If 
he  can  be  kept  alive  to  the  14th  day,  the  21st,  the  36th,  or  even 
the  60th  day,  recovery  will  probably  ensue.  Every  day,  every 
hour  of  existence  preserved  and  sustained  is  a  great  gain.  The 
risks  that  he  runs  are  due  to  debility  or  to  the  influence  of  the 
secondary  affections.  We,  so  to  speak,  cure  the  patient  by  pre- 
venting him  from  dying.  .  .  .  Herein  lies  the  secret  of  the 
treatment  of  fever.  We  watch  the  progress  of  the  disease  through- 
out its  varying  phases  ;  we  meet  by  judicious  treatment,  as  they 
arise,  the  symptoms  of  secondary  and  local  malady ;  we  sustain  the 
system  as  far  as  practicable ;  we  preserve  the  sufferer  at  the  least 
expense  to  the  constitution ;  and  we  wait  patiently  until  the  hour 
shall  strike  when,  in  accordance  with  the  mysterious  law  of 
periodicity,  the  fever  shall  have  departed  and  convalescence  shall 
have  begun." 

Murchison  employs  a  striking  metaphor  when,  to  the  same  effect, 
he  says — "  A  patient  with  typhus  is  like  a  ship  in  a  storm  ;  neither 
the  physician  nor  the  pilot  can  quell  the  storm ;  but  by  tact, 
knowledge,  and  able  assistance,  they  may  save  the  ship." 

Mosler,  of  Greifswald,  says  that  he  has  up  to  the  present  tried 
the  methods  mentioned  by  Murchison  for  the  treatment  of  typhus  : 
the  water  treatment,  the  use  of  large  doses  of  quinine,  alcoholic 
*  ^ectures  on  Fever.     1874,     Pages  83  and  84. 


310  TYrHUS   FEVER. 

stimulants,  and  nourishing  food.  Suitable  combinations  of  these 
measures  are  recommended  by  him  as  the  best  way  of  dealing  with 
typhus,  and  by  means  of  them  he  obtained  brilliant  results  in  an 
epidemic  observed  by  him  in  1867,  when  only  8  deaths  occurred 
among  94  patients,  the  mortality  being  8*7  per  cent,  compared  with 
the  average  laid  down  by  Griesinger  as  ranging  between  15  and  20 
per  cent.  In  the  same  epidemic,  before  suitable  treatment  had  as 
yet  come  into  use,  of  36  patients  20  died,  which  gave  a  death-rate 
of  55  per  cent.  We  are,  therefore,  justified  in  concluding  that 
even  the  mortality  in  typhus  may  be  reduced  to  an  inconsiderable 
figure  by  a  persistent  water-treatment,  carried  out  with  the  aid  of 
the  thermometer,  especially  when  combined  with  the  use  of  quinine 
and  of  the  other  remedies  already  mentioned. 

The  administration  of  alcoholic  stimulants  in  typhus  should 
not  be  a  matter  of  routine.  The  sagacious  physician  owes  it  to 
his  patient  and  to  his  own  reputation  to  decide,  in  each  case  after 
full  consideration,  whether  these  remedies — potent  for  evil  no  less 
than  for  good — are  to  be  prescribed  or  withheld.  Stokes's  views 
on  this  subject,  contained  in  the  twenty-seventh  of  his  Lectures  on 
Fever  (Edition  of  1874,)  are  thoroughly  sound  and  philosophical. 
After  pointing  out  that,  in  his  practice,  cases  had  occurred  in  which 
either  no  wine  was  used,  or  it  was  sparingly  employed,  or  it  was 
not  ordered  until  after  the  middle  period  of  the  fever,  he  goes  on  to 
speak  of  the  anticipative  treatment  by  stimulants — that  is,  their 
administration  at  an  early  stage  of  fever,  when  the  sagacity  of  the 
physician  enables  him  to  foretell  the  occurrence  of  great  prostration 
of  nervous  energy.  Under  such  circumstances  he  gives  stimulants 
oy  anticipation.  In  adopting  this  practice  we  follow  the  old  maxim, 
"  venienti  occurrite  morbo,"  and  we  take  into  account  the  character 
of  the  prevailing  epidemic,  and  the  previous  medical  history  of  the 
patient.  The  effect  of  each  dose  of  alcohol  should  be  carefully 
watched  and  noted. 

The  management  of  some  of  the  complications  and  sequelae  of 
typhus  remains  to  be  discussed. 

1.  Pulmonary  Congestion  and  Bronchitis  are  best  treated  by 
poulticing,  dry  cupping,  and  the  application  of  stimulating  liniments 


TYPHUS    FEVER.  311 

to  the  chest  by  rubbing — for  example,  compound  camphor  liniment, 
acetic  turpentine  liniment.,  and  so  on.  Iodine  may  also  be  applied 
in  the  form  of  an  oleate,  or  in  combination  with  water  and  glyce- 
rine— the  stronger  preparations  destroy  the  absorbent  power  of  the 
skin.  Internally,  the  most  useful  remedies  are  iodide  of  potassium 
and  bark  (in  convalescence),  quinine  and  iron,  quinine  and  arsenic 
in  pill,  digitalis.  In  gangrene  of  the  lung,  free  stimulation,  chlo- 
rate of  potassium  and  borax,  large  doses  of  quinine,  guaiacol  (which 
is  obtained  by  the  destructive  distillation  of  guaiacum  resin  and  is 
contained  in  beech  creasote  to  the  amount  of  60  to  90  per  cent.), 
and  antiseptic  inhalations  of  carbolic  acid,  creasote,  tar  vapour, 
&c,  are  the  most  suitable  remedies. 

2.  Paresis  after  the  fever  requires  a  generous  diet,  mineral  tonics, 
strychnin,  and  massage,  with  galvanism,  shower-baths,  and  sea- 
bathing in  summer.  Tincture  of  perchloride  of  iron  is  an  excellent 
remedy  in  incontinence  of  urine,  and  in  the  female  this  infirmity 
is  often  at  once  relieved  by  cauterising  the  orifice  of  the  urethra 
with  nitrate  of  silver. 

3.  In  addition  to  the  measures  suggested  in  Chapter  V.  (page  63) 
for  the  relief  of  convulsions,  it  is  right  to  mention  that  Hudson,  in 
1837,  recorded  a  case  of  recovery  after  two  severe  fits  of  convul- 
sions in  typhus,  the  treatment  adopted  consisting  in  the  abstraction 
of  ten  ounces  of  blood  by  wet  cupping  from  the  neck  and  purging 
with  calomel.  In  a  case  of  typhoid  fever  in  a  lady,  complicated  with 
epileptoid  convulsions,  the  treatment  adopted  by  Hudson  consisted  in 
withholding  wine,  cutting  off  the  hair,  applying  cold  to  the  head  and 
leeches  behind  the  ears ;  also,  in  the  exhibition  of  grain  doses  of 
calomel  at  short  intervals.  This  lady  recovered  perfectly.  She 
never  had  epilepsy  before  her  fever,  nor  did  she  afterwards  suffer 
from  it. 

4.  Bedsores  may  be  avoided  to  a  large  extent  by  careful  nursing 
and  by  the  use  of  an  annular  air-cushion,  a  water  bed,  or  a  spring 
bed.  The  threatened  parts  should  be  protected  by  being  kept  dry, 
and  painted  twice  a  day  with  a  solution  of  one  part  of  sheet  gutta- 
percha in  eight  parts  of  pure  chloroform,  or  equal  parts  of  white 
of  egg  and  rectified  spirit,  or  equal  parts  of  collodion  and  castor-oil. 


312  TYPHUS   FEVER. 

When  the  sores  have  formed,  they  should  be  washed  and  dressed 
antiseptically.  An  excellent  stimulating  application  is  composed 
of  two  parts  of  castor-oil  and  one  of  balsam  of  Peru  spread  on  lint, 
or  carbolised-oil  (1  in  40,  that  is,  2-|  per  cent.).  These  dressings 
should  be  protected  by  a  layer  of  oiled  silk,  or  else  covered  with  some 
poultice  less  septic  than  linseed  meal,  such  as  the  yeast,  carrot, 
chlorine,  or  charcoal  poultice. 

5.  When  phlegmasia  or  thrombosis  of  the  femoral  veins  occurs, 
the  foot  and  leg  of  the  affected  side  must  be  raised,  and  a  long  wide 
flannel  bandage  should  be  applied  from  the  feet  upwards.  If 
thrombosis  is  present,  denoted  by  a  hard  painful  cord  in  the  situa- 
tion of  the  femoral  vein,  strips  of  lint  smeared  with  equal  parts  of 
glycerine  and  extract  of  belladonna  may  be  laid  along  the  affected 
part,  and  covered  with  the  flannel  swathe  as  before. 

6.  (Edema  of  the  lower  extremities  generally  yields  to  a  generous 
diet,  and  tonics  like  iron  and  quinine  and  strychnin. 

The  dieting  of  a  typhus  fever  patient  should  be  conducted  on 
precisely  the  same  principles  as  those  which  guide  us  in  managing 
an  enteric  fever  patient.  The  reader  is,  therefore,  referred  to  the 
Chapter  on  the  "  Curative  Treatment  of  Enteric  Fever,"  where  the 
subject  is  considered  in  detail. 

During  convalescence,  the  patient  recovering  from  typhus  should 
be  warned  against  assuming  the  upright  position  too  soon,  or 
exposing  himself  to  cold.  The  returning  appetite  should  be  held 
in  check  for  the  first  two  or  three  days.  On  the  third  day, 
with  a  clean  tongue  and  a  quiet  pulse,  a  piece  of  boiled  white  fish,  or 
chicken,  or  the  hollow  part  of  a  tender  mutton  chop,  may  be  allowed. 
Costive  bowels  should  be  relieved  by  sipping  water  in  mouthfuls 
frequently,  or  by  the  administration  of  enemata  of  cold  water. 
Tonics  may  be  given  with  advantage ;  but  of  these  the  most  potent 
are  exercise  in  the  open  air,  and  change  of  residence  to  the  country, 
the  seaside,  or  the  mountain  slope. 


313 


.    CHAPTER  XXXII. 
Relapsing,  Famine,  or  Spirillum  Fever. 

Nomenclature— Definition — ^Etiology  (historical  sketch) — Mode  of  Preva- 
lence —Predisposing  Causes — Geographical  Distribution — Exciting  Cause- 
Bacteriology — Spirillum,  Obermeieri — Inoculation  Experiments — One  Attack 
of  Relapsing  Fever  confers  no  immunity  against  a  second. 

In  describing  this  form  of  Continued  Fever,  I  am  at  the  serious 
disadvantage  of  never  having  seen  a  case  of  the  disease  in  my 
hospital  or  private  practice.  This  fact,  after  well-nigh  twenty 
years'  experience  in  two  hospitals — one  of  them,  Cork-street  Fever 
Hospital,  the  great  epidemic  hospital  of  the  south  side  of  Dublin — 
leads  me  to  dispute  in  the  strongest  manner  the  accuracy  of 
Hirsch's  unqualified  and  dogmatic  statement  that  "  there  can  be 
no  doubt  that  the  disease  is  endemic  in  Ireland."  a  Although  this 
disease  is  personally  unknown  to  me,  the  descriptions  of  relapsing 
fever  by  Murchison,  H.  Lebert,  C.  A.  Ewald,  and  others,  are  so 
admirable  that  it  becomes  possible  to  picture  to  oneself  what  this 
form  of  continued  fever  must  be  in  its  clinical  aspect. 

Nomenclature — Relapsing  Fever,  Famine  Fever,  Spirillum 
Fever  (Vandyke  Carter,  1882),  Typhinia  (Farr,  1859),  Bilious 
Typhoid  Fever,  Yellow  Fever  of  the  British  Islands  (Graves  and 
Stokes,  1826),  "A  Five  Days'  Fever  with  Relapses"  (Rutty, 
1770),  Synocha  (Cullen,  1769),  Miliary  Fever  (Ormerod  and 
Watson,  1848). 

Germ. — Recurrens  (Ewald),  Ruckfallsfieber,  recurrirendes  Fieber 
Die  Hungerpest,  Armentyphus,  Febris,  vel  Typhus  Recurrens 
(Hirsch,  1859),  Riickfallstyphus  (Lebert,  1870),  Das  wiederkeh- 
rende  Fieber  (Obermeier,  1869). 

French — Fievre  a  rechute,  Typhus  a  rechute,  Fievre  recurrente, 
Fievre  a  recidive. 

*  Handbook  of  Geograph.  and  Historical  Patholoyy.  New  Syd.  Soc.  Vol.  I., 
page  614. 


31  i  RELAPSING    FEVER. 

ltal. — Febbre  a  recidive,  Febbre  ricorrente. 

Span. — Fiebre  recidiva. 

Swedish. — Recurreuta  Feber  (Cf.  Forhandlingar  vid  Svenska 
Lakare-Sallskapets,  1865,  p.  110,  and  1868,  p.  73). 

Norwegian  or  Danish. — Recidiv-Feber,  Galbefeber. 

Dutch. — Galkoorts  (i.e.,  Biliary  Fever). 

Definition. — A  specific  contagious  febrile  disease,  characterised 
by  the  presence  in  the  blood  during  the  febrile  paroxysm  of  a 
spiral  bacterium,  called  after  its  discoverer  the  Spirillum  Obermeieri ; 
by  a  critical  defervescence  after  5  or  7  days,  which  is  followed  by 
a  remission  lasting  7  or  8  days,  and  by  a  relapse  on  or  about  the 
fourteenth  day,  lasting  some  3  days.  This  fever  prevails  chiefly 
in  the  form  of  an  epidemic  during  seasons  of  scarcity  and  famine. 
It  is  unaccompanied  by  an  eruption,  but  jaundice  is  present  in 
some  20  per  cent,  of  the  cases.  The  death-rate  is  not  high,  being 
from  5  to  7  per  cent.  After  death,  the  liver  and  spleen  are  com- 
monly found  enlarged.     A  second,  or  even  a  third  relapse  may  occur. 

iEtiology. — The  first  minute  account  of  an  epidemic  of  Relapsing 
Fever  dates  from  the  years  1739  and  1741,  and  we  owe  it  to  Dr. 
Rutty .a  He  described  it  as  "  a  fever  of  six  or  seven  days'  dura- 
tion, terminating  in  a  critical  sweat.  .  .  .  ;  here  the  patients 
were  subject  to  a  relapse  even  to  a  third  or  fourth  time,  and  yet 
recovered."  It  followed  hard  upon  the  scarcity  caused  by  seasons 
of  unexampled  severity  in  the  years  1739-40.  "  It  was  far  from 
being  mortal,"  adds  Rutty,  who  goes  on  to  say — ';  I  was  assured  of 
seventy  of  the  poorer  sort  at  the  same  time  in  this  fever,  aban- 
doned to  the  use  of  whey  and  God's  good  providence,  who  all  recovered, 
while  those  who  had  generous  cordials  and  great  plenty  of  sack 
perished." 

In  an  historical  sketch  of  the  fevers  which  were  "  epidemical  " 
in  Ireland  during  the  last  and  at  the  commencement  of  the  present 
century,  Drs.  Barker  and  Cheyne,  writing  in  1821,  observed: 
"  Certain  it  is,   that   the  fever  in  1800  and  1801  very  generally 

a  A  Chronological  History  of  the  Weather  and  Seasons,  and  of  the  Prevailing 
Diseases  in  Dublin,  with  their  various  Periods,  Successions  and  Revolutions,  during 
the  space  of  forty  years.     Dublin.     8vo.     1770. 


RELAPSING    FEVER.  ?>lf> 

terminated  on  the  5th  or  7th  day  by  perspiration  ;  that  the  disease 
was  then  very  liable  to  recur  ;  that  the  poor  were  the  chief  sufferers 
by  it ;  and  that  it  was  much  more  fatal  amongst  the  middling  and 
upper  classes  in  proportion  to  the  number  attacked." 

Barker  and  Cheynea  were  the  historians  of  the  great  epidemic 
of  1817-1818;  Graves  and  Stokes  of  that  of  1826-1828.  Other 
outbreaks  occurred  in  Great  Britain  and  Ireland  in  1842-1843  and 
1847-1848  ;  as  well  as  in  Silesia  in  the  last-named  years  (Diimmler 
and  von  Barensprung).  A  very  full  and  excellent  account  of  the 
epidemic  of  1847  in  Ireland  will  be  found  in  the  7th  and  8th  Vols, 
of  the  New  Series  of  the  Dublin  Quarterly  Journal  of  Medical  Science 
(1849).  There  was  a  great  epidemic  at  St.  Petersburg  and  Odessa 
in  1863,  and  a  second  epidemic  occurred  in  Silesia  in  1867  and 
1868.  In  the  latter  year  relapsing  fever  reached  Berlin  for  the 
first  time,  frequently  recurring  up  to  1873.  In  1868  relapsing 
fever  re-appeared  in  Great  Britain  also,  an  epidemic  beginning  in 
London  in  July  of  that  year,  and  lasting  until  June,  1871.  In 
Liverpool  relapsing  fever  caused  355  deaths  in  1870,  207  deaths  in 
1871,  and  25  deaths  in  1872. 

Seventy-seven  deaths  from  relapsing  fever  were  registered  in 
England  in  the  ten  years  1880-89.  Of  these,  33  occurred  in  males 
and  44  in  females.  A  few  deaths  occurred  every  year  in  Scotland 
up  to  1879. 

So  far  as  Ireland  is  concerned,  the  Registrar-General,  Dr.  T.  W. 
Grimshaw,  has  kindly  furnished  me  with  the  following  Return  of 
the  Number  of  Deaths  from  Relapsing  Fever,  registered  in  Ireland 
during  the  ten  years,  1881-90  : — 

1881  ...  1  1886  ...  3 

1882  ...  1  1887  ...  0 

1883  ...  1  1888  ...  5 

1884  ...  2  1889  ...  2 

1885  ...  4  1890  ...  3 

In  reference  to  this  table,  it  is  to  be  remembered  that  the  Regis- 

a  An  Account  of  the  Rise,  Progress,  and  Decline  of  the  Fever  lately  Epidemical 
in  Ireland.     Dublin  :  Hodges  &  M'Arthur.     1821. 


316  KELAPSING    FEVER. 

trar-General  is  not  responsible  for  the  diagnosis,  and  the  eminently 
contagious  nature  of  relapsing  fever  suggests  grave  doubts  as  to  its 
accuracy  in  the  cases  embodied  in  the  return. 

As  regards  its  mode  of  prevalence,  Murchison  draws  the  fol- 
lowing conclusions  from  the  history  of  the  disease:  — 

1.  Relapsing  fever  is  an  epidemic  disease  in  a  stricter  sense 
than  even  typhus.  It  may  disappear  entirely  for  years  from  those 
places  where  at  other  times  it  rages  most  fiercely. 

2.  Epidemics  of  relapsing  fever  have  usually  co-existed  with 
epidemics  of  typhus,  and  have  always  appeared  under  circum- 
stances of  distress  or  famine. 

3.  In  mixed  epidemics  the  relative  proportion  of  typhus  and 
relapsing  cases  has  varied  at  different  times  and  places ;  but,  as  a 
rule,  the  proportion  of  relapsing  cases  has  been  much  greater  at 
the  commencement  than  towards  the  close  of  the  epidemic,  and 
with  the  advance  of  the  epidemic  typhus  has  taken  the  place  of 
relapsing  fever. 

Predisposing  Causes. — Hirscha  shows  clearly  that  the  preva- 
lence of  relapsing  fever  is  not  dependent  upon  climate,  is  little 
influenced  by  weather  or  season,  and  seems  to  bear  no  relation  to 
the  soil,  as  regards  altitude,  configuration,  geological  formation, 
and  the  like. 

The  disease,  further,  shows  no  preference  for  race  or  nationality. 

As  regards  sex,  of  2,115  cases  admitted  into  the  London  Fever 
Hospital  in  twenty-three  years  (1848-70),  1,279  were  males,  and 
only  836  were  females.  Murchison  thinks  that  this  curious  result 
is  due  to  the  fact  that  far  more  males  than  females  belong  to  the 
class  of  tramps  and  vagrants,  who  constitute  a  large  proportion  of 
the  cases  of  relapsing  fever. 

This  disease  attacks  all  ages — in  the  London  Fever  Hospital  the 
youngest  patients  were  two  boys  aged  5  months,  the  oldest  was  a 
man  aged  75.  The  percentages  of  all  the  cases  were — under  15 
years,  18*9  ;  from  15  to  25  years,  35*9  ;  25  years  and  upwards, 
45-2.     The  mean  age  of  typhus  patients  was  (as  already  men- 

a  Handbook  of  Geographical  and  Historical  Pathology.  New  Syd.  Soc. 
Vol.  I.,  pages  606,  et  seq. 


RELAPSING    FEVER.  317 

tinned)  29*33  years,  or  about  3  years  above  the  mean  age  of  the 
whole  population ;  but  the  mean  age  of  relapsing  fever  patients 
was  only  24-41  years,  or  two  years  under  that  of  the  population 
at  large. 

While  its  area  of  distribution,  as  we  will  show  presently,  is 
much  more  limited  than  that  of  typhus,  it  is  an  undoubted  fact 
that  relapsing  fever  and  typhus  often  coincide  remarkably  in 
time  and  place,  relapsing  fever  appearing  to  be  associated  in  a 
very  conspicuous  manner  with  epidemics  of  typhus.  But,  as 
Hirsch  points  out,  the  most  striking  analogy  to  typhus  which 
relapsing  fever  manifests,  comes  out  in  the  relation  of  the  origin 
of  the  disease  to  all  those  conditions  of  social  misery  which  play  so 
decided  a  part  in  the  history  of  typhus  outbreaks.  As  Engela 
says  of  it  in  his  account  of  "  the  Bukowina  Fever,"  relapsing  fever 
is  peculiarly  a  "  morbus  pauperum." 

As  regards  the  Geographical  Distribution  of  relapsing  fever,  in 
Europe,  the  British  Islands  (and  particularly  Ireland),  Russia,  and 
Germany  (with  the  exception  of  the  south),  Austria,  the  Levantine 
States,  and  the  islands  of  the  Eastern  Mediterranean,  have  been  mo.«t 
frequently  and  most  severely  visited.  On  the  other  hand,  Scandi- 
navia, Switzerland,  France,  Italy,  and  the  Iberian  Peninsula, 
seem  to  have  been  hitherto  exempt,  or  nearly  so,  from  visitations 
of  the  disease.  From  Norway,  however,  Danchersen  reports 
{Norsk  Magazin  for  Lcegevidenskaben,  1865,  xix.,  p.  76)  the  preva- 
lence of  epidemics  from  1858  to  1861,  and  again  in  1865,  in  the 
medical  or  dispensary  district  of  Vadso,  inhabited  by  a  poor  fishing 
population. 

In  Ireland,  during  the  epidemic  of  1826-28,  relapsing  fever  often 
assumed  the  character  of  bilious  typhoid,  so  much  so  that  Graves 
and  O'Brien b  were  constrained  to  explain  cases  of  that  kind  as 
yellow  fever. 

Outside  Europe,  one  of  the  most  extensive  centres  of  relapsing 
fever  and  of  bilious  typhoid  is  India. 

a  Oest.  med.  Jahrb.     1847.     Vol.  III.,  p.  249. 

b  Transactions  of  the  Med.  Assoc,  of  the  King  and  Queen's  College  of  Physicians 
in  Ireland.     1828. 


318  RELAPSING  FEVER. 

An  extensive  epidemic,  described  by  Dr.  Vandyke  Carter,8,  who 
gave  the  disease  the  name  of  "  Spirillum  Fever,"  occurred  in  1877— 
78-79  in  Western  India,  coincident  with  a  period  of  famine  due  to 
prolonged  drought  and  complete  failure  of  the  rice-crop. 

The  disease  also  occurs  along  the  North  African  Coast,  including 
Egypt  and  Algeria,  as  well  as  in  Abyssinia.  In  1864-65  it  pre- 
vailed in  certain  parts  of  China.  Since  1844,  it  has  occasionally 
appeared  in  some  of  the  Eastern  States  of  the  North  American 
Union.  Central  and  South  America,  Australia,  and  Polynesia,  have 
apparently  escaped  the  disease  up  to  the  present. 

Exciting  Cause. — That  there  is  a  specific  poison  in  relapsing 
fever,  communicable  from  the  sick  to  the  healthy,  is  proved  beyond 
all  doubt  by  evidence  similar  to  that  which  has  been  adduced  in  the 
case  of  typhus.  At  one  time  (in  1847)  Virchow  held  that  the 
disease  was  not  contagious,  but  he  must  have  abandoned  this  heresy, 
for  Hirschb  says:  "There  exists  no  doubt  whatever  in  the  expe- 
rience of  all  observers,  and  according  to  the  experimental  inocu- 
lations, that  relapsing  fever  (or  bilious  typhoid)  is  contagious." 

Bacteriology. — Since  Obermeier's  discovery  in  1873,c  no  doubt 
remains  that  for  relapsing  fever,  at  all  events,  there  exists  a  specific 
germ,  or  (as  Lebert  calls  it)  a  protomyces.d  Obermeier's  spirilla 
differ  onlv  in  size  from  similar  filaments  originally  discovered  in 
stagnant  water  by  Ehrenberg  in  1838,  and  named  by  him  Spiro- 
chete plicatilis  {airelpa,  a  coil;  yavr%  a  hair).  Another  spiro- 
chete was  found  in  the  mucus  of  the  gums  by  Steinberg  in  1862. 
This  he  named  Spirillum  buccale.  It  has  since  been  described  by 
F.  Cohn  under  the  name  Spirochete  denticola.  The  three  forms 
are  closely  allied  and  may  be  regarded  as  different  species  of  one 
genus  or  different  varieties  of  one  species  (Murchison).  The 
following  excellent  account  of  what  is  now  known  as  the  Spirillum 

a  Spirillum  Fever  of  Bombay.     1877. 

b  hoc.  cit.     Page  614. 

c  Vcrkommen  feinster,  eine  Eigenbewegung  zeigender  Fdden  im  Blute  von  Re- 
cur renzhranken.  Ueber  Pilzparasiten  im  Blute  bei  Recurrens,  x.,  1873.  Loc.  cit. 
Centralblatt  fur  die  med.  Wissenschaften,  xi.,  145.     1873. 

d  Gk.  vpunos,  first ;  (ivk7)s,  a  fungus. 


RELAPSING    FEVER.  319 

of  Eelapsing  Fever,  or  the  Spirochete  Obermeieri(Cohn)is  given 
by  von  Jaksch  :a — 

The  spirillum  was  first  noticed  by  Obermeier  in  the  blood  of  a 
patient  suffering  from  relapsing  fever.  It  has  since  been  seen  by 
many  observers,  but  most  authorities  are  agreed  that  it  is  to  be 
found  only  during  the  paroxysms  of  the  disease,  and  that  as  the 
temperature  falls  the  bacilli  disappear^  When  a  specimen  of 
blood  containing  them  is  placed  under  the  microscope,  the  bacilli 
appear  as  long  and  very  delicate  unsegmented  threads  twisted  into 
spirals.  Their  average  length  is  about  six  or  seven  times  the 
diameter  of  a  red  blood-corpuscle.  They  have  a  brisk  vibratile 
movement  in  the  direction  of  their  long  axis.  This  motion,  when 
the  blood  is  examined  with  a  low  power,  gives  to  the  eye  a  peculiar 
impression  of  disturbance,  and  will  immediately  lead  the  practised 
observer  to  look  for  the  presence  of  spirilla.  If  he  then  increases 
the  power,  and  still  better,  if  he  employs  an  oil  immersion  lens  with 
Abbe's  condenser  and  a  small  diaphragm,  the  spirilla  come  clearly  into 
view.  These  bodies  are  extremely  sensitive  to  reagents  of  all  kinds. 
Even  the  addition  of  distilled  water  will  cause  them  to  disappear. 

The  number  of  spirilla  which  are  to  be  seen  together  in  a  speci- 
men of  blood  varies  greatly,  and  often  bears  no  relation  to  the  in- 
tensity of  the  fever. 

If  the  blood  is  examined  in  the  intervals  of  the  disease,  provided 
another  paroxysm  be  impending,  it  displays  peculiar  refractive 
bodies  resembling  diplococci,  which  are  especially  numerous  when 
the  paroxysm  sets  in ;  and  just  as  it  begins,  they  even  seemed  to 
von  Jaksch,  in  certain  cases  to  grow  out,  as  it  were,  into  short  thick 
rods,  from  which  the  spirilla  were  finally  evolved.  Before  those 
of  von  Jaksch  similar  observations  had  been  made  by  Sarnow c ; 
and,  pending  further  confirmation,  it  seems  probable  that  these  bodies 
are  the  spores  of  spirilla  which  have  so  long  been  sought  for. 

a  Clinical  Diagnosis.  By  Dr.  Rudolf  v.  Jaksch.  Translated  from  the 
second  German  edition  by  James  Cagney,  M.D.  London  :  Charles  Griffin  & 
Co.     1890.     Pages  30  and  31. 

b  In  opposition  to  this  view,  see  Naunyn.  Centralblatt  filr  Bacterioloc/ie  und 
Parasitenkunde.     IV.  376.     1888. 

c  Der  Ruckfallstyfjhus  in  Halle  a.  S.  im  Jahre,  1879-81.  Inaugural  Dissertat 
Leipzig.     1882. 


320  RELAPSING?   FEVER. 

Since  both  the  spirilla  and  the  forms  just  mentioned  have  been 
met  with  as  yet  only  in  the  blood  of  persons  suffering  from  re- 
lapsing fever,  their  great  importance  as  a  clinical  test  is  apparent. 

Monkeys  have  been  inoculated  with  success  from  man,a  but  inocu- 
lations of  mice,  rabbits,  sheep,  and  pigs  gave  negative  results.  The 
spirilla  were  found  in  the  blood  of  the  inoculated  monkeys  in  great 
numbers,  and  also  in  the  brain,  lungs,  liver,  kidneys,  spleen,  and  skin. 
They  are  believed  to  be  the  cause  of  the  disease  (Crookshank). 

Moschutkovsky,b  of  Odessa,  was  the  first  to  attempt  to  produce 
infection  by  inoculating  the  blood  of  relapsing  fever  patients  on 
healthy  men,  and  he  proved  not  only  the  communicability  of  the 
disease,  but  also  the  specific  pathogenetic  significance  of  the  para- 
site. A  further  result  of  his  researches  was  to  prove  the  identity 
of  relapsing  fever  and  the  so-called  "  bilious  typhoid,"  a  view 
already  maintained  by  Griesinger  and  the  Russian  physicians  on 
anatomical  and  pathological  grounds. 

The  period  of  incubation  in  the  inoculated  cases  was  never  more 
than  8  or  less  than  5  days.  In  monkeys,  Vandyke  Carter  found  it 
to  vary  from  30  hours  to  5  days.  When  the  disease  is  taken  in  the 
natural  way,  its  latent  period  is  on  the  whole  shorter  than  that  of 
typhus.  According  to  Lebert,  it  varied  at  Breslau  from  3  to  7 
days — it  was,  however,  oftener  over  than  under  5  days.  Murchison 
analysed  32  cases,  and  found  that  in  not  one  instance  did  the  stage 
of  incubation  exceed  12  days,  while  in  13  it  did  not  exceed  5  days. 
In  3  cases  the  attack  was  immediate  on  exposure  to  the  infection. 

One  attack  of  relapsing  fever  confers  little  or  no  immunity  from 
a  subsequent  visitation.  This  was  proved  in  all  the  great  epidemics 
of  the  present  century  both  at  home  and  abroad,  but  a  classical 
observation  is  that  of  Sir  Robert  Christison,  Bart.,  who  in  the  out- 
break of  1817-19  experienced  no  fewer  than  three  separate  attacks 
within  fifteen  month  sin  his  own  person.0 

a  H.  Vandyke  Carter.  Lancet,  1879.  Vol.  I.,  page  84  ;  and  1880,  Vol.  I., 
page  662.    See  also  Koch.    Deutsche  med.  Wochenschrift.    1879.    Nos.  16,  27,  30. 

b  Centralblatt  fiir  die  med.  Wissenschr.  1876.  No.  11.  Petersb.med.  Wochen- 
schrift.    1878.     No.  27.     Archiv.  fur  Hin.  Med.     1879.     XXIV.,  page  80. 

c  Edin.  Med.  Journal.     January,  1858.     Page  583. 


321 


CHAPTER  XXXIIL 
Clinical  Description  of  Relapsing  Fever. 

Sudden  onset. — High  Temperature. — Abrupt  crisis.  Intermission. — Re- 
lapse.— Low  mortality. — "  Bilious  Typhoid  "  (Griesinger). — "  Yellow  Fever  of 

the  British  Islands"    (Graves). —  Heart   murmurs. — Stages   and   duration. 

Temperature. — Complications  and  Sequelae. 

Relapsing  Fever  usually  begins  with  great  suddenness.  In  some 
cases,  indeed,  the  actual  outburst  of  the  disease  may  be  preceded 
by  such  prodromata  as  malaise,  weariness,  pain  and  heaviness  in  the 
head,  flying  pains  in  the  extremities,  and  thirst. 

Whether  such  prodromata  have  occurred  or  not,  the  patients  are 
suddenly  seized  with  chills  or  rigors,  frontal  headache,  and  pains  in 
the  back,  neck,  and  limbs.  They  complain  of  giddiness  and  noises 
in  the  ears  (tinnitus).  The  vertigo  rather  than  their  weakness 
compels  them  to  take  to  bed  at  once.  This  cold  stage  is  quickly 
followed  by  a  reaction,  characterised  by  flushing  of  the  face, 
epistaxis  in  many  cases,  a  dry,  hot  skin,  increase  of  pains, 
throbbing  headache,  and  burning  thirst.  The  appetite  is,  in  most 
cases,  completely  lost ;  but  there  may  be  voracious  appetite 
(boulimia).  This  was  noticed  in  the  epidemic  of  1843  in  the  prac- 
tice of  the  London  Fever  Hospital,  and  also  in  that  of  1847,  in 
Ireland,  especially  by  Mr.  Kelly,a  of  Mullingar,  Co.  Westmeath, 
The  pulse  becomes  very  quick,  reaching  120  as  a  rule,  or  far 
exceeding  even  this  rate.  It  is  generally  full  and  firm,  and  its 
rapidity  is  not  of  evil  omen.  On  this  point,  Niemeyer  says  that 
the  pulse  is  more  frequent  in  relapsing  fever  than  in  almost  any 
other  disease. 

The  tongue  is  large  and  moist,  rarely  becoming  dry,  cracked  and 
brown.  The  bowels  are  constipated  ;  tenderness  at  the  epigastrium 
is   complained   of.      Nausea    and    vomiting   are   not   uncommou 

a  DM.  Journ.  of  Med.  Science,   New  Series.     Vol.  VIII.,  page  64.     1848. 

Y 


322  RELAPSING   FEVER. 

symptoms.  A  slight  catarrhal  jaundice  may  be  present,  but  this  is 
to  be  distinguished  from  the  much  more  serious  hgematogenous 
jaundice  which  not  infrequently  renders  the  disease  malignant 
(bilious  typhoid).  The  vomited  matter  may  consist  of  green  bile, 
or  else  of  blood  like  coffee-grounds  (black  vomit).  Sleeplessness  is 
a  common  and  distressing  symptom  ;  but  delirium  is  much  less 
usual  than  in  typhus. 

The  urine  is  scanty  and  high-coloured,  and,  according  to 
Obermeier,  shows  that  parenchymatous  nephritis  exists.  When 
jaundice  is  present,  the  urine  contains  bile-pigment  and  bile-acids. 
Physical  examination  reveals  considerable  enlargement  of  both 
liver  and  spleen  even  at  an  early  stage.  There  is  no  eruption  of  a 
specific  kind,  but  a  roseolar  rash  has  not  infrequently  been  observed, 
as  well  as  true  petechias  in  certain  cases  and  crops  of  sudamina  in 
or  after  the  sweating  stage. 

The  fever  runs  very  high  in  relapsing  fever — temperatures 
between  105°  and  108*7°  being  quite  common  shortly  before  the 
crisis.  The  thermometer  at  the  beginning  rises  so  abruptly  that 
within  twelve  or  twenty-four  hours  of  the  earliest  symptoms  it  may 
reach  104°  to  106°  F. 

Towards  the  close  of  the  first  week — sometimes  as  early  as  the 
third,  or  as  late  as  the  tenth  day — more  usually  on  the  fifth,  sixth, 
or  seventh  day — all  the  symptoms  subside  like  magic.  In  a  few 
hours — eight  or  nine — the  pulse  sinks  to  70,  60,  50,  or  even  lower, 
and  the  temperature  runs  down  from  its  acme  of  106°  to  108°  to 
several  degrees,  it  may  be,  below  normal.  This  sudden  crisis  is 
ushered  in  by  profuse  sweating — the  patients  being  literally  bathed 
in  perspiration  for  some  hours ;  more  rarely  by  diarrhoea,  epistaxis, 
menstruation,  or  intestinal  haemorrhage.  The  perspiration  which 
accompanies  crisis  has  an  acid  reaction  and  "  a  characteristic  dis- 
agreeable smell "  (Cormack,  1 843).  Occasionally  a  brief  spell  of 
frenzied  delirium  immediately  precedes  the  critical  defervescence. 

During  the  next  few  days,  while  the  pulse  remains  slow,  the 
temperature  gradually  rises  towards  normal,  the  tongue  cleans, 
appetite  returns,  and  the  patients  feel  and  declare  themselves  well. 

In  most  cases,  however,  on  or  about  the  seventh  day  from  the 


RELAPSING    FEVER.  323 

crisis,  without  warning  or  assignable  cause,  the  relapse  sets  in. 
This  is,  in  fact,  a  repetition  of  the  initial  symptoms  of  the  first 
attack.  Sometimes  this  secondary  paroxysm  is  even  more  severe 
than  the  first,  so  far,  at  all  events,  as  high  temperature  is  con- 
cerned ;  but  the  febrile  movement  is  generally  of  shorter  duration, 
lasting  only  three  or  four  days,  and  terminating  by  another  crisis, 
with  its  attendant  phenomena. 

Now  and  again,  there  is  a  second  relapse,  coming  on  about  the 
21st  day,  and  lasting  two  or  three  days.  Rarely,  even  a  third  or 
a  fourth  relapse  may  occur ;  but,  on  the  other  hand,  there  may  be 
no  relapse  at  all  in  exceptional  cases,  the  passing  off  of  the  first 
paroxysm  terminating  in  convalescence  without  further  suffering. 

By  far  the  most  common  ending  of  relapsing  fever  is  in  recovery. 
The  death  rate  in  most  epidemics  is  only  2  or  3  per  cent.,  and 
it  rarely  exeeeds  6  or  8  per  cent.  When  death  does  occur,  it  is 
the  outcome  of — (1)  collapse  and  general  paralysis  during  the 
paroxysm  ;  (2)  exhaustion  during  the  interval ;  (3)  some  com- 
plication or  secondary  affection — such,  for  example,  as  acute  pneu- 
monia or  nephritis  with  urasmia. 

Pregnant  females  invariably  abort,  and  often  die,  in  relapsing 
fever.  i 

Bilious  Typhoid  (Griesinger). — "  Under  certain  influences,  still 
unknown,"  writes  Niemeyer,a  "  possibly,  merely  as  a  result  of  the 
action  of  a  particularly  intense  contagion,  relapsing  fever  assumes 
a  very  malignant  character.  The  appearance  of  the  disease  is 
especially  modified  by  excessive  participation  of  the  biliary  appa- 
ratus, and  in  most  cases  death  appears  with  severe  symptoms. 
Griesinger  describes  this  malignant  form  of  relapsing  fever  from 
his  observations  made  in  the  East,  and  terms  it  '  Bilious  Typhoid.' 
The  St.  Petersburg  epidemic  of  1864  to  1866,  where,  besides  simple 
recurrent  fever,  there  were  numerous  cases  of  bilious  typhoid, 
especially  at  its  commencement,  fully  confirmed  Griesinger's 
description  of  the  disease,  as  well  as  his  opinion  that  it  was  a 
severe  form  of  recurrent  fever."      We  have  already  seen   above 

a  Text-Booh  of  Practical  Medicine.  Revised  Edition.  London  :  H.  K. 
Lewis.     1880.     Vol.  II.,  page  662. 


324  RELAPSING    FEVER. 

that  this  view  is  altogether  borne  out  by  the  inoculation  experi- 
ments of  Moschutkovsky  and  others. 

According  to  Zorn,a  the  fever  does  not  run  so  high  in  this 
bilious  form  as  it  does  in  the  simple  variety.  It  is  not  uncommon 
for  peripheral  parts  to  feel  even  cold,  a  very  dangerous  symptom. 
The  same  writer  also  states  that  the  second  attack  or  relapse  occurs 
in  only  about  one  half  of  the  bilious  cases. 

Under  the  heading,  "  Yellow  Fever  of  the  British  Islands," 
Graves  b  detailed  a  number  of  cases  of  the  severe  form  of  Relapsing 
Fever,  just  now  described.  Nearly  twenty  patients  died  at  the 
Meath  Hospital  of  the  disease,  prominent  symptoms  of  which  were 
hardness  and  tenderness  of  the  abdomen  about  the  epigastrium  and 
hypochondria,  a  knotted  feel  of  the  abdominal  muscles,  general 
jaundice  of  a  bright  yellow  colour,  uneasiness  and  anxiety  of  coun- 
tenance, a  very  quick  and  hurried  pulse,  coldness  of  the  extremities, 
and  deep  purple  coloration  of  the  tip  of  the  nose,  the  cheeks,  and 
sometimes  of  the  toes  (local  asphyxia).  Another  notable  symptom 
was  abdominal  spasm,  to  which  the  hospital  nurses  gave  the 
expressive  and  (as  it  proved)  appropriate  name  of  "twisting  of 
the  guts,"  for  recent  intussusceptions  or  invaginations  of  the 
intestines  were  among  the  most  constant  pathological  conditions 
noticed  after  death. 

The  purple  coloration  of  the  nose  superadded  to  the  jaundice 
imparts  a  weird  and  frightfully  repulsive  appearance  to  the  patient 
sinking  under  this  malignant  form  of  relapsing  fever. 

In  the  epidemic  of  relapsing  fever  of  1847,  Dr.  Stokes  made  a 
number  of  observations  in  the  Meath  Hospital  on  the  condition  of 
the  heart  in  the  disease.  He  found  little  evidence  of  softening  of 
the  heart,  but  "  a  bellows  murmur,  or,  in  some  cases,  a  prolonga- 
tion of  the  systolic  sound,  was  common,  especially  in  the  relapse  ; 
but  this  did  not  result  from  carditis."  Dr.  Stokes's  observations 
were  borne  out  by  his  colleague,  Dr.  Cathcart  Lees.  The  murmur 
was  systolic  in  time,  basic,  and  travelled  not  infrequently  into  the 

a  Petersburg  Zeitschrift.     IX.  16. 

b  Clinical  Lectures  on   the  Practice  of  Medicine.     New  Syd.  Soc.  EditioD. 
Vol.  I.,  page  323.     1884. 


RELAPSING    FEVER.  'J>25 

great  vessels.  It  generally  diminished  in  intensity  when  the  patient 
sat  up,  and  Dr.  Stokes  regarded  it  as  of  anaemic  origin.  Stokes's 
researches  on  the  subject  have  been  amply  confirmed  by  R.  D. 
Lyons,  of  Dublin  (in  1861) ;  G.  P.  Tennent,  of  Glasgow  (in 
1871)  ;  W.  Zuelzer,  of  Breslau  (in  1867) ;  and  Obermeier,  of  Berlin 
(in  1869). 

When  cerebral  symptoms  occur  in  relapsing  fever,  they  are 
generally,  as  in  typhus,  independent  of  inflammation  of  the  brain 
or  its  membranes,  and  depend  either  on  cholaemia,  or  uraemia,  or 
some  other  form  of  blood-poisoning. 

Stages  and  Duration. — Four  well-defined  stages  may  be  recog- 
nised in  the  course  of  relapsing  fever:  they  are  those  of — (1)  the 
primary  paroxysm,  (2)  the  intermission,  (3)  the  relapse,  and  (4) 
convalescence. 

In  100  consecutive  cases  under  Murchison's  care,  and  accurately 
noted  by  him  in  his  case-books,  the  average  duration  of  the  primary 
paroxysm  was  5*96  days;  that  of  the  intermission  was  7'82  days  ; 
that  of  the  relapse  was  3*45  days — total  duration,  17*23  days. 
Under  ordinary  circumstances,  when  there  are  but  two  paroxysms, 
the  duration  of  relapsing  fever  to  the  commencement  of  permanent 
convalescence  is,  according  to  Murchison,  about  18  days. 

Temperature. — The  thermometer  begins  to  rise  before  the  initial 
rigor  and  while  the  pulse  is  still  normal.  It  reaches,  or  may  reach, 
104°-106°  F.  within  from  twelve  to  twenty-four  hours.  An  acme, 
or  fastigium,  is  attained  shortly  before  the  crisis  (105°-108'7°). 
During  the  paroxysm  there  are  usually  daily  remissions  of  one  or 
two  degrees  Fahrenheit — mostly  in  the  morning,  and  best  marked 
in  children.  Crisis  is  sometimes  ushered  in  with  a  rigor,  when 
the  temperature  falls  to  or  below  normal — a  fall  of  8°,  9°,  10°,  or 
even  13°,  occurring  in  a  few  hours.  In  one  case  the  thermometer 
fell  14-4°  in  twelve  hours!  For  two  or  three  days  after  the  crisis 
the  temperature  is  commonly  sub-normal  (96°,  94°,  or  even  as 
low  as  92°).  So  constantly  is  this  the  case,  that  this  low  tem- 
perature is  a  useful  diagnostic  sign.  In  the  relapse  the  maximal 
temperature  of  the  whole  attack  is  generally  recorded,  but  the 
hyperpyrexia  is  of  shorter  duration  than  in  the  primary  paroxysm. 


326  RELAPSING   FEVER. 

The  high  temperatures  in  relapsing  fever  entail  little  or  no 
danger  to  the  patient,  nor  do  they  produce  serious  cerebral 
symptoms. 

In  Plate  VI.,  are  two  charts  of  the  temperature  ranges  in 
relapsing  fever — one  copied  from  Wunderlich's  "  Medical  Ther- 
mometry," the  other  from  Murchison's  "  Treatise  on  the  Continued 
Fevers  of  Great  Britain." 

Complications  and  Sequelae. — 

1.  Pneumonia  is  said  to  be  more  common  in  relapsing  fever 
than  in  typhus,  but  Murchison  observed  this  complication  in  only 
4  or  5  out  of  600  cases. 

2.  Sudden  collapse  may  prove  rapidly  fatal,  and  has  been  known 
to  occur  at  any  stage  of  the  disease.  The  pulse  becomes  small, 
irregular,  or  imperceptible,  the  heart's  impulse  fails,  and  its  sounds 
are  blurred  or  obliterated,  the  whole  surface  is  cold  and  livid,  and 
the  patient  often  becomes  quite  insensible.  This  fatal  syncope  is, 
in  some  cases,  due  to  haemorrhage ;  in  others,  to  pre-existing 
organic  disease. 

3.  Haemorrhages  from  various  parts  are  not  uncommon,  and 
may  occur  at  any  stage.  The  most  usual  kind  of  haemorrhage  is 
epistaxis ;  but  bleeding  may  also  take  place  from  the  womb, 
stomach,  bowels,  kidneys,  and  ears. 

4.  The  spleen  is  commonly  much  enlarged.  It  may  rupture  or 
become  the  seat  of  thrombotic  abscesses. 

5.  "  One  of  the  most  remarkable  features  of  relapsing  fever," 
says  Murchison,  "  is  the  frequent  occurrence  during  convalescence 
of  a  peculiar  disease  of  the  eyes.  This  sequela  has  been  observed 
in  almost  all  epidemics,  but  is  never  met  with  after  typhus  or 
enteric  fever."  Among  other  writers  on  the  subject  we  find  Dr. 
Arthur  Jacob,  of  Dublin,  who  contributed  to  the  fifth  volume  (that 
for  1828)  of  the  "  Transactions  of  the  Association  of  Fellows  and 
Licentiates  of  the  King  and  Queen's  College  of  Physicians  "  a  paper 
entitled  "  On  internal  Inflammation  of  the  Eye  following  Typhus 
Fever."  The  disease,  as  described  by  Dr.  Mackenzie,  of  Glasgow 
(1843)  presents  two  distinct  stages — the  amaurotic  and  the  in- 
flammatory.    J.  A.  Estlander,  in  a  paper  published  in  1869 — 


flate   VR 

CHARTS  OF  TEMPERATURE  RANGES  IN  RELAPSING  FEYER 


fiff.I  Relapsing  fever 

Fak 

107    6 

105  8 

mo 

I0Z  2 
100-4 
98  6 
96  S 

C    2      3      4      S      6      7      8     &     /0    H     12    J3    H     IS      IS      7     18       9     W    *V 

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EmmaJJ.agedJffi.ajfo-itf^uifc'ZonfawJ7^ 


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Relapsing  fever  in  tke,JioT?<f/)Tv  fever  Hospital 
(Copied  from  ,Mi/rcJuso/i',s  'CbnJtrriicedfevers  of  Great  Britain'') 


of 


RELAPSING    FEVER.  327 

"  Ueber  Chorioiditis  nach  Febris  typhosa  recurrens  "a — showed  that 
the  starting  point  of  the  disease  is  in  the  chorioid,  and  especially 
in  the  ciliary  body.  Inflammation  is  lighted  up  here  by  some 
morbid  state  of  the  blood,  and  spreads  thence  to  the  vitreous  body, 
causing  the  "  amaurotic "  symptoms,  and  subsequently — but  not 
always — to  the  iris,  the  iritis  corresponding  to  the  "  inflammatory 
stage."  Recovery  is  tedious — in  most  cases  two  months  have  been 
necessary  to  effect  a  cure,  and  unless  carefully  treated,  the  disease 
may  end  in  permanent  loss  of  sight  (Murchison.)  Reference  on 
this  subject  may  also  be  made  to  a  paper  by  Luchhan,  in  Virchow's 
Archiv.,  volume  LXXXII  (1880),  entitled  "  Ohren-  und  Augen- 
erkrankungen  bei  Febris  recurrens" 

6.  Diarrhoea  and  Dysentery  often  complicate  or  follow  relapsing 
fever.  In  some  epidemics  they  are  among  the  chief  causes  of  death. 
These  troubles  come  on  suddenly  after  rigors,  and  are  accompanied 
by  vomiting.  Sometimes  the  patient  suffers  much  from  pain  and 
tenderness  over  the  lower  part  of  the  abdomen,  or  from  griping 
tenesmus. 

7.  Peritonitis  is  a  rare,  but  very  fatal  complication.  In  the 
epidemic  of  1847-48,  of  2,846  cases  of  relapsing  fever  in  the 
Glasgow  Infirmary,  7  died  from  peritonitis.  It  is  usually  secondary, 
depending  on  dysentery,  rupture  of  the  spleen,  or  splenic  abscess. 

R  Archiv.  fur  Ophthalmologic.  1869.  Band,  XV.  Abtheilung  II.,  page 
108. 


328 


CHAPTER  XXXIV. 

The  Diagnosis,  Prognosis,  Pathology  and  Treatment 
or  Relapsing  Fever. 

Diagnosis  from  :  Typhus,  enteric  fever,  simple  continued  fever,  remittent 
fever  ("jungle  fever"),  yellow  fever. — Presence  of  the  spirochsete  in  the  blood 
is  pathognomonic. — Pbognosis  and  Mortality  :  Unfavourable  symptoms. 
Pathological  Anatomy. — Treatment  :  no  specific  for  Relapsing  Fever. 
Hygienic  and  Expectant  Treatment. — Nitre. — Treatment  of  symptoms  and 
complications. — "  Bilious  Typhoid  "  (Griesinger.) — Convalescence. 

Diagnosis. — Relapsing  Fever  may  be  confounded  with  : — 

1.  Typhus. — In  forming  an  opinion,  regard  should  be  paid  to 
the  nature  of  other  cases  occurring  in  the  same  house  or  family, 
the  presence  or  absence  of  eruption,  the  presence  of  epistaxis,  jaun- 
dice, vomiting,  and  cardiac  murmur,  and  the  whole  clinical  history, 
which  is  quite  different  in  the  two  fevers. 

2.  Typhoid  or  Enteric  Fever. — The  differential  diagnosis  again 
turns  on  the  clinical  history,  the  occurrence  of  epidemics  of  relapsing 
fever  in  times  of  famine. 

3.  Simple  Continued  Fever  in  its  acute  form.  But  in  simple 
fever  no  relapse  occurs. 

4.  Eemittent  Fever. — This,  however  arises  from  malaria,  affects 
all  classes  of  the  community  alike,  and  is  not  contagious.  Besides, 
there  is  no  resemblance  between  the  intermissions  of  relapsing  fever 
and  the  remissions  of  remittent  fever.  Remittent  fever,  also,  is  a 
tropical  disease. 

5.  Yellow  Fever,  because  jaundice  may  be  present  in  relapsing 
fever,  particularly  in  that  form  now  known  as  "  bilious  typhoid  " 
(Griesinger.)  The  points  of  diagnosis  are :  yellow  fever  attacks 
all  classes  alike,  but  the  same  individual  once  only  in  his  life- 
time. It  is  a  most  mortal  disease.  Jaundice  is  nearly  always  a 
prominent  symptom  in  yellow  fever,  which  does  not  cause  great 
swelling  of  the  spleen.     Death  in  yellow  fever  is  usually  preceded 


RELAPSING    FEVER.  329 

by  "  black  vomit,"  which  is  rare  in  relapsing  fever.  The  diseases 
differ  completely  in  their  clinical  course,  and,  lastly,  yellow  fever 
is  checked,  almost  annihilated,  by  air-temperatures  below  70°  F. 

Dr.  William  Cayleya  very  properly  points  out  that  the  demonstra- 
tion of  the  spirochete  in  the  blood  will  now  distinguish  relapsing 
fever  from  all  other  febrile  diseases. 

Prognosis  and  Mortality. — Out  of  2,115  cases  of  relapsing 
fever  admitted  to  the  London  Fever  Hospital  from  1848  to 
1870,  inclusive,  only  39  proved  fatal — that  is  a  death-rate  of  1*84 
per  cent.,  or  about  1  in  54.  From  statistics  of  18,859  cases  with 
761  deaths,  Murchison  estimates  the  death-rate  of  relapsing  fever 
in  the  United  Kingdom  at  4-03  per  cent.,  or  1  in  24*78.  In  the 
epidemic  of  1877-79  in  Bombay,  however,  Vandyke  Carter 
observed  a  mortality  of  18*02  per  cent. 

The  rate  of  mortality  increases  with  advancing  age,  but  not  at 
all  to  the  same  extent  as  in  typhus.  Almost  all  published  statistics 
agree  in  assigning  a  higher  death-toll  to  the  male  sex.  The  mor- 
tality also  is  greatest  in  winter.  Lastly,  the  rate  of  mortality  is 
higher  at  the  beginning  and  height  of  an  epidemic  than  at  its  close. 
In  mixed  epidemics  of  typhus  and  relapsing  fever,  an  apparent 
exception  to  this  rule  is  observed,  owing  to  the  increasing  ratio 
which  the  typhus  cases,  with  their  higher  death-rate,  bear  to  relaps- 
ing fever  in  the  later  stages  of  the  outbreak. 

The  unfavourable  symptoms  in  relapsing  fever  are:  jaundice 
with  cerebral  symptoms,  purpura-spots  and  vibices,  copious  haemo- 
rrhages, suppression  of  urine  with  head  symptoms,  ataxic  symptoms 
(the  ''typhoid  state").  Again,  the  prognosis  is,  of  course,  un- 
favourably influenced  by  the  presence  of  a  complication  or  of  a 
chronic  organic  disease,  particularly  fatty  degeneration  of  the  heart. 

Pathological  Anatomy — The  post-mortem  appearances  of  re- 
lapsing fever  may,  according  to  Murchison,  be  summed  up  as 
follows : — 

1.  There  is  no  specific  or  constant  lesion. 

2.  The  most  common  lesions  are  enlargement  and  infarction  of 

a  Murchison's  Treatise  on  the  Continued  Fevers.  Third  Edition.  1884. 
Page  394. 


330  RELAPSING   FEVER. 

the  spleen,  slight  leukaemia,  congestion  of  the  liver  and  kidneys, 
jaundice,  dysentery,  and  pneumonia. 

3.  In  most  cases  nothing  can  be  discovered  in  the  liver,  or  in  tha 
bile-ducts,  to  account  for  the  jaundice.  In  exceptional  cases  only 
is  there  acute  atrophy  or  catarrh  of  the  ducts.  The  icterus,  or 
jaundice  has,  however,  been  characterised  by  Bock  and  Wyss  as  of 
hepatic  origin  (hepatogenous),  because  of  the  presence  of  the  bile- 
acids  in  the  urine.8, 

4.  No  lesion  can  be  discovered  in  the  brain  or  its  membranes, 
even  when  cerebral  symptoms  have  been  most  marked. 

Treatment. — "The  chief  promoting  causes  of  the  disease  being 
famine  and  contagion,"  writes  Dr.  T.  W.  Grimshaw,b  "  the  means 
for  prophylaxis  are  obvious."  "  Relapsing  fever,"  says  Murchison, 
"  is  the  appanage  of  poverty  and  destitution ;  and  the  more  com- 
pletely we  succeed  in  ameliorating  the  condition  of  the  poor,  parti- 
cularly in  times  of  famine,  the  more  successful  shall  we  be  in 
averting  the  disease." 

The  details  of  Preventive  Treatment  already  specified  in  Chapter 
IV.,  as  well  as  those  given  under  the  head  of  typhus,  apply  perfectly 
well  to  relapsing  fever. 

No  specific  for  this  disease  has  yet  been  discovered.  Quinine, 
digitalis,  and  the  salicylates  have  all  been  tried  and  found  wanting. 

Riessc  considered  that  he  obtained  satisfactory  results  from  sali- 
cylate of  sodium  in  a  single  dose  of  rather  more  than  90  grains 
("in  Einzelgaben  von  6*0  Grm."),  but  Ewald  was  not  able  to 
confirm  his  results  with  even  larger  doses. 

As  there  is  no  specific,  and  as  the  malady  is  not  very  dangerous 
to  life,  our  treatment  of  it  should  be  hygienic  and  expectant  to  a 
large  extent.  Lebert  puts  this  very  well  when  he  says  d : — "  Rest 
in  bed,  fresh  air,  cleanliness,  fever  diet,  milk,  soups,  meat  broths, 
cooling  drinks,  are  the  principal  things  to  be  attended  to.     If  the 

a  Studien  iiber  Febris  recurrens.     Berlin.     1869. 

b  Quain's  Dictionary  of  Medicine.     1883.     Art.  "  Relapsing  Fever." 

c  Typhus  recurrens  in  Berlin.  Berl.  klin.  Wochenschr.  1868.  No.  22. 
1869.     No.  31. 

d  Von  Ziemssen's  Cyclopcedia  of  the  Practice  of  Medicine.  Vol.  I.  Art.  "  Re- 
lapsing Fever."     1875. 


RELAPSING   FEVER.  331 

patient  has  an  appetite,  if  he  can  take  nourishment,  he  should 
have  not  only  more  but  better  fare — vegetables,  stronger  soups, 
meat,  and  particularly  wine.  Clear  pure  water  and  carbonic  acid 
water  are  the  beverages  best  borne." 

Murchison  gives  advice  to  the  same  effect  when  he  says : — 

"  1.  That  a  larger  quantity  of  nourishment  is  usually  required 
after  the  cessation  of  the  febrile  paroxysms  than  in  typhus,  and 
that  many  patients  during  the  fever,  and  especially  in  the  relapse, 
will  take  a  considerable  quantity  of  nutriment  with  relish,  and 
apparently  with  benefit. 

"  2.  That  alcoholic  and  other  stimulants  will  often  be  required 
about  the  time  of  crisis,  to  counteract  the  tendency  to  collapse. 
They  are  especially  indicated  in  persons  over  45  years  of  age,  and 
where  there  is  evidence  of  a  weak  heart." 

The  same  author  recommends  that  the  treatment  should  be  begun 
in  the  early  stage  with  an  emetic  of  ipecacuanha  and  antimony,  or 
of  mustard.  Constipation  should  be  counteracted  by  small  doses 
of  castor  oil  (a  teaspoonf  ul,  with  one  of  glycerine,  in  milk).  Mur- 
chison and  many  writers,  from  Baglivi  downwards,  speak  highly  of 
the  value  of  nitre  in  relapsing  fever.  It  acts  as  a  mild  aperient, 
an  efficient  diuretic,  and  a  preventive  of  uraemia,  and  (consequently) 
of  cerebral  symptoms  also.  The  formula  for  the  administration  of 
the  salt  runs  thus  : — 

1^.  Potassi  Nitratis,  gr.  60-120 ; 
Acid.  Nitric,  dilut.,  3j- ; 
Tincturse  Digitalis,  3sg»  > 
Aquae,  ad  §vi.  • 

M.  ft.  mist.     Signa  :  "  One  sixth  part  every  fourth  hour." 

To  fulfil  the  same  indications  as  the  foregoing,  Dr.  Cheyne's 
"  mild  anti-febrile  and  gently  stimulant  diaphoretic  "  (as  Graves  a 
calls  it)  may  be  prescribed  : — 

$.  Ammonii  Carbonatis,  gr.  60 ; 
Succi  Limonis,  §ii. ; 
Syrupi  Aurantii,  |ss. ; 
Aquas,  giiiss. 
M.  ft.  mist.     Signa  :  "  One-sixth  part  every  third  or  fourth  hour." 
a  Clinical  Lectures.     New  Syd.  Soc.     1884.     Vol.  I.,  page  318. 


332  RELAPSING    FEVER. 

Graves  improved  Cheyne's  prescription  by  substituting  carbonate 
of  sodium  for  carbonate  of  ammonium — thus,  in  a  modern  form  : — 

fy.  Sodii  Carbonatis,  gr.  60 ; 

Succi  Limonis,  §i.,  5vi. ; 
Misce  et  adde — 

Tinct.  Aurantii  Recentis,  3ii. > 

Syrupi  Aurantii,  §ss. ; 

Aquae,  ad  §vi. 
M.  ft.  mist.     Signa  :  "  One  sixth  part  every  third  or  fourth  hour." 

Graves  says  nothing  can  be  more  agreeable  in  flavour  than  this 
mixture.  The  citrate  of  sodium  which  is  formed  "determines 
gently  to  the  kidneys,  tends  to  keep  up  a  soluble  state  of  the 
bowels,  and  forms  a  most  grateful  and  refreshing  beverage." 

If  a  weaker  solution  is  preferred,  a  drachm  of  the  carbonate  of 
sodium  may  be  dissolved  in  five,  instead  of  four,  ounces  of  water. 

As  a  placebo,  Lebert  gives  small  doses  of  phosphoric  acid.  This 
formula  would,  probably,  meet  his  approbation : — 

]$.  Acidi  phosphorici  diluti,  3iss. ; 
Elixir.  Glusidi  (Saccharini),  3ss. ; 
Aquae,  ad  §iv. 
M.  ft.  mist.     Signa  :  "  A  tablespoonf ul  every  second  or  third 
hour." 

Bleeding  (venesection)  is  inadmissible  in  relapsing  fever  for 
reducing  temperature  or  any  other  purpose.  Niemeyer  sets  his 
face  even  against  cold*  baths,  on  the  ground  that  relapsing  fever, 
in  spite  of  the  high  temperature,  has  a  low  mortality.  He  thinks 
it  well  to  limit  ourselves  to  sponging  the  body  with  cold  lotions, 
and — if  the  cerebral  symptoms  are  severe — to  the  application  of 
ice  to  the  head.  Lebert  is  quite  in  accord  with  Niemeyer  on  this 
point  and  recommends  the  very  same  measures.  Should  they  fail 
to  relieve  headache  and  procure  sleep,  Murchison  says  recourse 
must  be  had  to  opium  or  hydrate  of  chloral. 

When  collapse  threatens,  Lebert  orders  an  ammoniated  tincture 
of  musk  as  follows  : — 


RELAPSING    FEVER.  333 

I£.  Moschi,  gr.  60  ; 

Ammonii  Carbonat.,  gr.  30  ; 
Olei  Mentha?,  min.  v. ; 
Alcoholis,  §ii. ; 
Aquae  Destillatae,  §v. 

Of  this  mixture,  thirty  drops  are  to  be  taken  in  a  tablespoonful  of 
sugar  and  water,  or  wine,  every  hour. 

Obstinate  diarrhoea  is  to  be  combated  by  alum,  tannin,  nitrate  of 
silver,  and  opium  (Lebert)  ;  or  by  small  doses  of  laudanum  in 
decoction  of  logwood,  or  an  astringent  mixture  containing  kino  or 
catechu  with  opium  (Murchison). 

For  dysentery  the  best  remedies  are  ipecacuanha  and  opium. 
They  may  be  prescribed  in  the  form  of  "  Twining's  Pill "  a  (ipeca- 
cuanha, blue  pill,  and  extract  of  gentian),  or  as  follows  (Mur- 
chison) :  — 

!E|.  Pulv.  Ipecac,  gr.  2  ; 

Pulv.  Ipecac.  Comp.,  gr.  5  ; 
Hydrargyri  cum  Creta,  gr.  3. 
Misce,  Fiat  Fulvis.     Signa  :  "  One  four  times  a  day." 

An  enema  of  starch  and  opium  should  be  used  from  time  to  time, 
if  there  is  tenesmus  ;  and  occasional  doses  of  castor-oil  are  useful  if 
the  stools  are  scanty  and  the  abdomen  is  distended. 

Should  dysentery  not  yield  to  these  means,  the  pharmacopoeial 
solution  of  the  pernitrate  of  iron  with  small  doses  of  opium  will  be 
found  an  excellent  remedy. 

Severe  epistaxis  should  be  controlled  by  plugging  the  nostrils 
and  posterior  nares. 

For  the  post-febrile  ophthalmia,  in  its  earlier  stages,  a  liberal 
diet,  tonics  (such  as  quinine  and  iron),  and  blisters  behind  the  ears, 
will  do  good.  When  iritis  declares  itself,  Mackenzie b  recom- 
mends leeching  the  temples,  continued  dilatation  of  the  pupils  with 
solution  of  belladonna  or  atropin,  blisters  behind  the  ears,  a  nutri- 

a  Cf.  Twining.     Diseases  of  Bengal.     1832. 
b  Loc.  cit.     1843. 


334  RELAPSING   FEVER. 

tious  diet,  and  one  of  the  following  powders  every  four  or  six  hours 
until  the  gums  are  touched  : — 

#.  Hydrargyri  Subchloridi,  gr.  12  ; 

Quininae  Sulphatis,  gr.  12-24; 

Pulv.  Opii,  gr.  3  ; 

Sacchari  Albi,  q.s.  ut  fiant  pulv.  xij. 
In  "bilious  typhoid,"    Griesinger   recommends   large  doses  of 
quinine  (10  to  30  grains  daily) — a  mild  purgative  of  salts,  castor- 
oil,  or  cream  of  tartar  (acid  tartrate  of  potassium)  having  been  first 
given  at  the  beginning  of  the  attack. 

During  the  convalescence  of  patients  who  have  become  exceed- 
ingly exhausted,  Lebert  considers  that  a  good  invigorating  fare  is 
best  supplemented  by  tincture  of  cinchona,  or  mild  preparations 
of  iron,  particularly  of  the  lactate.  This  last  may  be  given  to  the 
amount  of  three  to  eight  grains  daily,  in  pill  form,  with  extract  of 
gentian. 


3&5 


CHAPTER  XXXV. 
Enteric,  or  Typhoid,  Fever. 

General  Considerations. — Essential  difference  between  typhus  and  enteric 
fevers  not  recognised  in  the  past — reasons  for  this. — Evils  of  not  differentiating 
between  typhus  and  enteric  fevers. — Fundamental  distinctions. — Liebenneister's 
views. 

The  day  has  now  long  passed  by  since  the  doctrine  of  the  identity 
of  typhus  and  enteric  fever  attracted  any  number  of  adherents 
among  the  great  thinkers  of  the  Medical  Profession.  But  there 
was  a  time  when  this  doctrine  did  obtain  credence,  and  even  the 
commanding  genius  of  William  Stokes  clung  to  this  faith  with 
what  in  one  less  distinguished  would,  perhaps,  be  regarded  as 
obstinate  infatuation.  Writing  so  recently  as  1874,a  he  used  such 
expressions  as  these :  "  The  inexpediency  of  drawing  hard  and 
fast  lines  of  distinction  between  what  are  termed  typhus  fever  and 
typhoid  fever."  b  "  Fever  has  been  somewhat  arbitrarily  divided  into 
two  classes,  or  placed  under  two  great  headings — typhus  and 
typhoid."  c  "  Do  not  these  facts  point  to  the  conclusion  that  there 
is  but  a  slight  tension,  so  to  speak,  in  the  individuality  or  separate  cha- 
racters of  the  various  forms  of  fever,  and  that  in  their  essence  and 
from  a  practical  point  of  view,  they  may  be  looked  on  as  species 
rather  than  genera — the  genus  being  fever,  that  condition  on  which 
anatomical  investigations,  in  the  words  of  Graves,  throw  but  a 
negative  light  ?  "  d 

I  think  there  are  three  chief  reasons  why  in  the  past  the  essen- 
tial differences  between  typhus  and  enteric  fever  were  not  recog- 
nised. 

a  Lectures  on  Fever.     London  :  Longmans,  Green  &  Co.     1874. 
b  Loc.  cit.     Page  44. 
c  Loc.  cit.     Page  78. 
d  Loc.  cit.    Page  89. 


336  ENTERIC  FEVER. 

First,  in  presence  of  the  defective  hygiene  of  former  days  the 
"  typhoid  state,"  of  which  mention  has  so  often  been  made  in  these 
pages,  was  much  more  commonly  observed  than  it  is  now.  It 
complicated  enteric  fever  no  less  than  typhus. 

Secondly,  there  can  be  no  reasonable  doubt  that  enteric  fever 
was  of  much  less  frequent  occurrence  before  the  days  of  water 
closets  and  of  water  carriage  of  "  night  soil."  Murchison  especially 
alludes  to  the  fact  that  enteric  fever  has  much  increased  in  Edin- 
burgh of  late  years,3  and  his  explanation  is  that  this  increase  of 
the  fever,  "followed  the  introduction  of  new  sanitary  arrange- 
ments— the  substitution  for  the  scavenger  and  niglitmen  of  drains 
opening  into  the  interior  of  the  houses,  but  with  a  water  supply 
insufficient  to  prevent  the  escape  of  sewer  emanations."  b 

Thirdly,  from  the  non-recognition  of  the  separate  identity  of 
typhus  and  typhoid,  it  followed  almost  as  a  matter  of  course  that 
cases  of  both  these  fevers  were  treated  in  the  same  wards — nay,  in 
adjoining  beds,  perhaps,  sometimes  in  the  same  bed.  The  natural 
consequence  was  that  the  typhoid  patients  contracted  typhus, 
which  soon  declared  itself  with  its  stupor  and  macuhe — thus 
rendering  confusion  worse  confounded." 

The  evils  which  accrue  from  non-recognition  of  the  essential 
difference  of  typhus  and  typhoid  as  regards  their  origin  are  clearly 
shown  by  Mr.  J.  Spear,  in  his  report  to  the  Local  Govern- 
ment Board  on  appearances  of  typhus  fever  in  various  parts  of 
England  during  the  year  1886-87.c  In  Leeds,  Hartlepool,  Carlisle, 
Middlesborough,  Oldham,  Newcastle-on-Tyne,  and  Flint,  typhus 
gained  a  footing  through  the  neglect  of  unrecognised  cases  ;  and  in 
Liverpool  this  is  the  common  experience  with  respect  to  constantly 
recurring  localised  outbreaks.  In  a  previous  year  (1885),  Mr. 
Spear  met  with  an  outbreak  in  Workington.  The  disease  spread 
by  a  demonstrable  chain  of  cases  to  several  adjoining  villages  and 

a  Treatise  on  the  Continued  Fevers.    Third  Edition.    1884.    Pp.  443  and  444. 

b  Cf.  W.  T.  Gairdner,  M.D.  Public  Health  in  relation  to  Air  and  Water, 
Edinburgh.     1862. 

c  Sixteenth  Annual  Report  of  the  Local  Government  Board.  1886-87.  Page 
269. 


ENTERIC    FEVER.  337 

towns,  localised  epidemics  of  considerable  importance  resulting.  In 
each  one  of  these  several  invasions  the  disease  had  been  regarded  as 
typhoid  or  enteric  fever,  with  the  result  that  inefficient  measures  for 
preventing  its  spread  had  been  applied.  In  1883,  Mr.  Spear  in- 
vestigated a  notable  outbreak  of  typhus  in  a  large  charitable  insti- 
tution at  Hammersmith.  The  disease  had  been  spreading  for  three 
months  amongst  the  children,  infecting  at  least  nineteen  of  them, 
as  well  as  several  of  the  Sisters  of  Mercy  and  two  priests  from 
outside,  before  its  true  nature  was  recognised.  The  priests  were 
supposed  to  be  suffering  from  "  typhoid." 

From  his  experiences  Mr.  Spear  was  led  to  conclude  that  con- 
siderable outbreaks  of  typhus  might  occur  without  medical  recogni- 
tion, the  disease  being  mistaken  for  typhoid  fever  or  (in  children) 
for  measles,  influenza,  &c,  and  that  the  result  of  such  diagnostic 
failure  was  not  merely  official  mis-information,  but  often  the 
unchecked  spread  of  the  disease.  He  observes — "  It  is  a  matter 
the  extreme  importance  of  which  to  the  general  community  has 
not  yet  been  sufficiently  appreciated,  or  practical  instruction  in  the 
diagnosis  of  fever  would  occupy  a  more  prominent  place  in  medical 
education."  a 

Liebermeister  °  puts  the  matter  very  well  when  he  says,  "  In  fact, 
the  only  likeness  between  typhus  and  typhoid  fever,  except  that 
they  are  both  infectious  diseases,  is  that  in  both  diseases  many  of 
the  cases  are  attended  with  severe  and  long-continued  fever.  In 
every  other  respect  they  are  different.  Typhus  fever  has  many  more 
analogies  with  smallpox,  measles,  and  scarlet  fever,  than  with 
typhoid  fever.  Typhoid  fever,  in  its  aetiology  and  mode  of  propa- 
gation, resembles  dysentery  and  cholera  much  more  than  it  does 
typhus. 

"  The  real  fundamental  difference  between  the  two  diseases  is 
this :  Typhus  fever  is  a  purely  contagious  disease ;  typhoid  fever 
belongs  to  the  miasmatic-contagious  diseases.  Typhus  can  be 
transmitted  directly   from   person  to  person;   its  contagion  is  as 

a  Loc.  cit.     Page  287. 

b  Von  Ziemssen's  Cyclopaedia  of  the  Practice  of  Medicine.  Vol.  I.,  page  41. 
Art.  "Typhoid  Fever." 


338  ENTERIC   EEVER. 

intense  and  evident  as  is  that  of  the  acute  exanthemata.  Typhoid 
fever,  on  the  contrary,  is  never  [directly]  transmitted  from  person 
to  person.  There  can  be  no  doubt  that  this  profound  difference  in 
the  mode  of  propagation  depends  upon  an  essential  difference  in 
the  poison  producing  the  two  diseases.  Every  classification,  there- 
fore, which  is  grounded  on  scientific  principles,  must  separate  these 
two  diseases  widely  from  each  other." 

As  we  shall  see  in  the  sequel,  Liebermeister  is  too  dogmatic  in 
absolutely  denying  the  transference  of  typhoid  or  enteric  fever  from 
person  to  person,  but  there  can  be  no  doubt  that  the  disease  belongs, 
as  he  supposed,  to  the  miasmatic-contagious  rather  than  to  the 
contagious  group.  That  is,  an  affected  body  furnishes,  indeed,  the 
morbific  germs  of  typhoid  fever,  but  these  germs  must  undergo  a 
further  development  after  they  leave  that  body,  most  probably  in 
immediate  relation  to  sewer  gas  or  the  products  of  decomposition 
(putrefaction),  before  they  attain  their  complete  infecting  power 
and  become  capable  of  reproducing  the  disease  in  another  body  to 
which  they  have  gained  access  by  one  or  other  of  the  recognised 
channels  of  infection. 


339 


CHAPTER  XXXVI. 

Enteric  Fever  (confined). 

Nomenclature. — Synonyms. — Definition. — Literature  and  History. — 
Geographical  Distribution. — ^Etiology  :  Predisposing  causes  :  sex,  age,  defec- 
tive sewerage  and  drainage,  season,  temperature  and  moisture,  soil  and  under- 
ground water. — Immunity. — Exciting  cause. — Bacteriology  :  Bacillus  typho- 
sus (Eberth).  —  Supposed  spontaneous  origin  of  enteric  fever. — This  doctrine 
is  now  untenable. — Resting  spores. — Paths  op  Infection  :  currents  of  air, 
drinking  water,  milk,  meat. —Mode  of  invasion. 

Nomenclature. — Probably  there  is  no  other  disease  which  has  so 
many,  and  at  the  same  time  such  unsuitable,  names.  Objections 
can  be  raised  on  etymological,  pathological,  and  etiological  grounds 
respectively  to  each  of  the  three  names  by  which  this  fever  is  best 
known  to  English  authorities.  It  is  not  like  typhus,  and  therefore 
the  term  "  Typhoid  "  in  its  literal  sense  is  inapplicable  to  it.  The 
fever  is  not  in  any  sense  the  result  of  the  characteristic  intestinal  lesions 
of  the  disease,  and  so  the  term  "  Enteric  "  is  unsuitable  from  a  patho- 
logical point  of  view.  Lastly,  mere  putrefaction  is  certainly  not  the 
proximate  cause  of  the  fever,  and  so  Murchison's  ingenious  name  of 
"  Pythogenic  Fever,"  derived  from  what  he  endeavoured  to  show 
was  the  cause  of  the  fever  {Trvdo<yevr)<i,  from  irvOwv-TrvOofiaL, 
putresco — and  yevvda),  to  beget,  to  engender,  to  produce)  is  serologi- 
cally incorrect.  Putrefaction  does  not  engender  typhoid  or  enteric 
fever,  however  much  its  presence  may  contribute  to  the  potency  of 
the  specific  poison  of  the  disease. 

Having  regard,  however,  to  their  general  acceptance  in  English- 
speaking  communities,  and  waiving  their  strict  propriety  from  a 
pathological  and  an  etymological  standpoint  respectively,  the  terms 
"  enteric  fever  "  and  "  typhoid  fever  "  are  probably  the  best  names 
for  the  disease  we  can  adopt. 

Since  1871  the  term  "Enteric  Fever"  has  been  used  officially 
in  the  Reports  of  the  Army  Medical  Department. 


340  ENTERIC   FEVER. 

It  is  also  adopted  in  the  Reports  of  the  Registrars-General  for 
England,  Scotland,  and  Ireland  ;  and  under  it  such  classical  writers 
as  Murchison  and  Hilton  Fagge  have  described  the  disease.  To 
it,  therefore,  I  will  give  the  preference  in  the  succeeding  account 
of  this  form  of  Continued  Fever. 

The  name  "  typhoid  "  we  owe  to  Louis,  who  in  1 829  wrote  of  the 
fever  as  "  Fievre  typho'ide."  It  was  adopted  by  Chomel  in  1834, 
and  by  Alex.  Stewart  in  1840. 

I  select  the  following  additional  names  for  this  disease,  as  they 
refer  to  its  characteristics,  its  symptoms,  or  its  course : — 

From  its  supposed  resemblance  to  typhus  it  was  called  Typhus 
Nervosus  (de  Sauvages,  1760)  ;  Typhus  Mitior  and  Synochus 
(Cullen,  1760);  Typhus  gangliaris  vel  entericus  (Ebel,  1836, 
Schonlein,  1839). 

From  its  seasonal  prevalence  it  is  known  in  America  as 
Autumnal  or  Fall  Fever  (Austin  Flint,  1852). 

From  its  remittent  character  in  children  it  was  called  Infantile 
Remittent  Fever  (Evans  and  Maunsell,  1836). 

From  its  long  duration  it  was  described  as  Febris  lenta 
(Forestus,  1591);  Slow,  or  Lent,  Fever  (Strother,  1729). 

From  its  supposed  nervous  or  hysteric  character  it  was  called 
Low  Fever,  Nervous  Fever  (Gilchrist,  1734)  ;  Slow  Nervous  Fever 
(Huxham,  1739). 

From  its  septic  character  it  was  called  Febris  putrida  (Riverius, 
1623) ;  Fievre  ataxique  (Pinel,  1798) ;  Enterite  septicemique 
(Piorry,  1841). 

From  its  gastric  and  intestinal  symptoms  and  lesions  it  became 
known  as  Febris  gastrica  (Bellonius,  1640);  gastrisches  Fieber 
(Richter,  1813);  Fievre  gastrique  {Diet,  des  Sciences  3fe'dicales, 
1816);  Epidemic  Gastric  Fever  (Cheyne,  1833) ;  Gastric  Fever 
(Craigie,  1837) ;  Bilious  Fever  (Sir  John  Pringle,  1750,  and  Rutty, 
1770);  Schleimfieber  (Kanz,  1795);  Fievre  muqueuse ;  Mucous 
or  Fituitous  Fever  (Copland,  1844);  Gastro-enterite  (Broussais, 
1816);  Dothienenterite  (Bretonneau,  1826);  Entente  folliculeu^e 
(Cruveilhier,  1835);  Enteric  Fever  (Ritchie,  1846);  Intestinal 
Fever   (W.  Budd,  1856)  ;    Enterica  (sc,  Febris)   (Samuel  Wilks). 


ENTERIC    FEVER.  341 

The  German  names  under  this  heading  are  Typhus-abdominalis 
(Autenrieth,  1822);  Darm-typhus  (same  authority):  Ileo-typhus 
(Griesinger,  1857). 

From  its  supposed  mode  of  origin  it  was  called  Nightsoil  Fever 
(Brown,  1855)  ;  Cesspool  Fever;  and,  as  before  mentioned,  Pytho- 
genic  Fever  (Murchison,  1858).  Also  "  Worm  Fever"  is  a  trivial 
term  for  the  disease. 

The  synonyms  for  Typhoid  Fever  in  common  use  in  the  chief 
European  tongues  are  the  following : — Germ.  Abdomiual-typhus, 
Darm-typhus;  French,  Fievre  typhoide,  Dothi^n^nterie;  Ital.  Febbre 
tit'oide,  Tifo  enterico,  Tifo  intestinale,  Tifo  addominale,  Ileotifo ; 
Span.,  Fiebre  tifoidea,  Dotinenteria;  Dutch,  Slependekoorts  (i.e., 
slow  fever),  Darmkoorts,  Zenuwzinkingkoorts  a  (Becking)  ;  Danish 
and  Norivegian,  Tyfoidfeber ;  Swedish,  Tyfoidfeber. 

Definition. — An  acute,  specific,  infective  fever  prevailing  usually 
as  an  endemic  rather  than  an  epidemic  disease.  The  virus  of  this 
fever  develops  in  the  dejections  of  the  sick  and  in  presence  of  the 
decomposition  of  certain  organic  substances.  The  most  important 
and  prominent  symptoms  are :  a  gradual  onset,  which  is  often  in- 
sidious or  marked  by  slight  chills,  a  feeling  of  lassitude,  or  diarrhoea 
and  a  gradually  rising  temperature,  with  an  "  easel-like  "  range  on 
the  chart,  culminating  in  a  high  fever.  The  fever,  at  its  fastigium 
or  acme  runs  a  continuous,  in  the  beginning  and  closing  stages,  a 
remittent,  course.  Prostration  of  the  nervous  system  and  head- 
ache ;  later  on,  but  only  in  the  severer  cases,  dulling  of  the  intellect 
and  often  delirium,  of  a  low  muttering  kind  ;  dilatation  of  the  pupils  ; 
a  tendency  to  heart  failure.  Continuous  diarrhoea,  frequently  in- 
testinal haemorrhages,  enlargement  of  the  spleen,  meteorism,  ten- 
derness and  gurgling  (gargouillement)  in  the  ileo-caescal  region. 
An  inconstant  roseolar  rash  appears  from  the  end  of  the  first  week 
in  successive  crops,  but  never  becomes  petechial.  A  tendency  to 
relapse  is  often  observed.  The  anatomical  characters  are :  an  in- 
flammatory tumefaction,  ulceration,  and  sloughing  of  the  glands  of 
the  small  intestine,  and  less  frequently  of  those  of  the  large  intes- 
tine also — the  solitary  and  agminate  glands  (Peyer's  patches)  of 
B  I.e.,  Nervous  catarrhal  fever. 


342  ENTERIC   FEVER. 

the  ileum  being  especially  affected — as  well  as  tumefaction  of  the 
mesenteric  glands  and  spleen,  the  presence  of  specific  bacilli  in  these 
organs — the  Bacilli  typhosi  of  Eberth  (1880).  In  certain  rare  cases 
the  intestinal  lesions  may  recede  or  fail  to  appear.  The  duration 
of  the  illness  amounts  on  an  average  to  3  or  4  weeks — according 
to  Murchison  to  24\3  days.     (After  Zuelzer  a  and  W.  Cayleyb). 

Literature  and  History. — Hippocrates c  is  supposed  to  have  re- 
ferred to  Enteric  Fever  under  the  name  7rupeT09  r)fitTpiTalo<i. 
(" Semitertian  Fever" — a  form  of  ague  described  by  Galen). 

In  Germany,  von  Hildenbrand,d  in  1810,  first  clearly  distinguished 
between  typhus  and  enteric  fevers.  Early  in  the  present  century 
Broussais  e  and  others  in  France  maintained  that  a  "  gastro-enterite  " 
was  the  essential  cause  of  "fever."  They  were  led  to  the  false 
theory  of  the  symptomatic  nature  of  fever  by  the  discovery  that  the 
intestines  of  those  who  died  in  Paris  of  what  we  now  call  enteric 
fever  were  inflamed  and  ulcerated. 

Serres  and  Petit f  considered  that  the  intestinal  lesions  were 
specific,  depending  on  the  introduction  of  a  poison  into  the  system, 
and  of  an  eruptive  nature  like  the  pustules  of  smallpox. 

In  1818  Bretonneau  of  Tours  undertook  certain  anatomical 
researches,  the  result  of  which  led  him  to  propose  for  this  disease 
the  name  of  dothienenterie,  or  dothienenterite,  to  indicate  the 
Special  nature  of  the  intestinal  lesion  which  accompanies  it — from 
the  Greek  BoOirjv,  a  small  abscess  or  boil  (Lat.  furunculus)  and 
evrepov,  the  intestine.  The  second  form  of  the  word  contains  the 
French  equivalent  "  -ite "  of  the  terminal  -itis,  signifying  inflam- 
mation. This  cumbrous  term  was  adopted  by  Bretonneau's  illus- 
trious pupil,  Trousseau,5  and  under  it  the  disease  is  described  in 
the  Clinique  medicate  de  V Hotel  Dieu  de  Paris. 

a  Real-Encyclopadie  der  Gesammten  Heilkunde.  Wien  und  Leipzig  :  Urban 
und  Schwarzenberg.     1885.     Erster  Band.     Art.  "Abdominal  Typhus." 

b  Fowler's  Dictionary  of  Practical  Medicine.  London  :  J.  &  A.  Churchill. 
1890.     Art.  "Typhoid  Fever." 

c  Editio  Foesii.     1624.     Page  961. 

d  Loc.  cit.     Wien.     1810. 

e  Examen  des  Systemes  modernes  de  Nosologie.     Paris.     1816. 

f  Traite  de  la  Fievre  Entero  me'senterique.     Paris.     1813. 

g  "  De  la  maladie  a  laqnelle  M.  Bretonneau  a  donne  le  nom  de  dothienenterie, 
ou  de  dothiinentiiite."     Archives  Gen.  de  Med.     Se"rie  I.,  torn,  x.,  169.     1826. 


ENTERIC    FEVER.  343 

In  1829,  P.  C.  A.  Louis  published  in  Paris,  in  two  volumes,  his 
"  Recherches  sur  la  maladie  connue  sur  les  noms  de  gastro-enterite, 
fievre  putride,  adynamique,  &c."  and  in  that  work  he  first  proposed 
the  name  of  "  Fievre  typho'ide"  for  the  disease. 

It  was  not  until  the  year  1836  that  accumulating  clinical  and 
pathological  evidence  led  to  the  conclusion  that  two  distinct  dis- 
eases— typhus  and  enteric  fever — were  being  confounded  with  each 
other.  The  credit  of  establishing  the  differential  diagnosis  of  the 
two  fevers  is  divided  by  Murchison  among  a  number  of  observers — 
R.  Perry,"  of  Glasgow  (1836) ;  H.  C.  Lombard,"  of  Geneva  (1836) ; 
Gerhard  and  Pennock,0  of  Philadelphia,  U.S.A.  (1836);  Shattuck,d 
of  Boston  (1838) ;  H.  C.  Barlow,e  of  London  (1840) ;  and  A.  P. 
Stewart/  of  London  (1840). 

In  a  series  of  admirable  papers  published  between  1849  and 
1853,  Sir  William  Jenner  maintained  that  typhus  and  the  so-called 
"  typhoid  fever"  were  as  distinct  as  any  two  of  the  exanthemata. 
His  writings  did  much  to  set  the  vexed  question  at  rest,  although 
many  years  elapsed  before  the  specific  distinctness  of  the  two  fevers 
was  finally  and  universally  recognised.  Barrallier,  of  Toulon,  in 
1861,  put  the  question  in  an  almost  epigrammatic  form  as  follows  : 
"  Elles  sont  separ^es  l'une  de  l'autre  par  leurs  causes,  leurs  sym- 
ptomes,  leur  marche,  leur  duree,  leurs  caraeteres  anatomiques  ;  elles 
appartiennent  r^ellement  a  la  meme  classe  de  maladies,  les  fievres 
essentielles  specifiques,  mais  elles  constituent  des  genres  a  part, 
comme  la  rougeole  et  la  scarlatine  dans  le  groupe  des  fievres  erup- 
tives." 

The  principal  modern  writers  on  the  fascinating  subject  of 
enteric  fever  are :  Charles  Murchison,g  W.  Cayley,h  and  C.  Hilton 

a  Edin.  Med.  and  Surg.  Journ.     Vol.  XLV.     1836. 
b  Dubl.  Journ  of  Med.  Science.     Vol.  X.     1836. 

c  American  Journ.  of  Med.  Set.  Vols.  XIX.  and  XX.  1836.  February  and 
August. 

a  American  Med.  Examiner,  Feb.  and  March.     1840. 

e  Lancet.     February  20,  1840. 

f  Edin.  Med.  and  Surg.  Journ.     Oct.,  1840. 

e  Treatise  on  the  Continued  Fevers  of  Great  Britain.     Third  Edition.     1884. 

b  Croonian  Lectures.     1880, 


344  ENTERIC    FEVER. 

Fagge,a  in  our  own  country ;  August  Hirsch,*>  Professor  of  Medi- 
cine in  the  University  of  Berlin  ;  Karl  Liebermeister,c  Professor  of 
Clinical  Medicine  in  Tubingen ;  and  Wilhelm  Zuelzer, a  of  the 
University  of  Berlin,  in  Germany  ;  and  Charles  Sraart,e  Major  and 
Surgeon,  U.  S.  Army,  in  America.  In  the  work  of  the  last-named 
author,  the  section  on  Pathological  Anatomy  is  profusely  illustrated 
with  a  series  of  most  beautiful  photo-reliefs,  heliotypes,  photographs 
on  steel,  and  chromo-lithographs.  In  these  the  pathological  ap- 
pearances of  the  intestines  in  typhoid  or  enteric  fever  are  shown  in 
perfection.  I  venture  to  say  that  such  another  collection  of  draw- 
ings does  not  exist. 

Geographical  Distribution. — Enteric  fever  prevails  all  over  the 
world.  The  sketch  of  its  geographical  distribution  given  by  Hirsch 
justifies  the  designation  of  an  ubiquitous  disease.  Its  incidence  is 
as  wide  as  the  globe.  Until  recently,  the  Tropics  were  supposed 
to  enjoy  an  immunity  from  it,  but  this  is  not  so,  although  the 
disease  is,  no  doubt,  less  prevalent  in  lower  latitudes  than  in 
higher.  This  fever  is  met  with  in  India — often  obviously  lying 
hidden  behind  the  "  continued  and  remittent  fever  of  the  Anglo- 
Indian  physicians — in  Burma,  Cochin  China,  Reunion,  Mauritius, 
Madagascar,  Tahiti,  Senegambia,  Bermudas,  the  West  Indies, 
Cayenne,  and  Brazil — all  tropical  or  sub-tropical  localities.  It 
would  seem,  then,  that  climate  does  not,  in  and  by  itself,  exert  a 
determining  influence  on  the  occurrence  of  enteric  fever  (Hirsch). 

This  disease  is  endemic  in  the  British  Islands.  It  is  apparently 
most  common  in  England,  more  common  in  Ireland  than  in  Scotland, 
and  in  the  last-named  country  more  common  on  the  west  than  on 
the  east  coast  (Mnrchison).  It  is  also  endemic  in  nearly  all  parts 
of  the  Continent.  In  Iceland,  where  it  is  known  by  the  name  of 
"  Landfarsot  "  (sickness  of  the  country),  it  is  met  with  every  year — 

a  The  Principles  and  Practice  of  Medicine.  Art.  "  Enteric  Fever."  1886 
and  1891. 

b  Handbook  of  Geographical  and  Historical  Pathology.  New  Syd.  Soc.  Trans- 
lation.    1883-1886. 

c  Von  Ziemssen's  Cyclopaedia  of  the  Practice  of  Medicine.     Vol  I.     1875. 

&  Real-Encyclopadie  der  gesammen  Heilkunde.     Art.  "Abdominal  Typhus." 

e  The  Medical  and  Surgical  History  of  the  War  of  the  Rebellion.  Part.  III. 
Volume  I.     Medical  History.     Washington,  1888. 


ENTERIC    FEVER.  345 

not  infrequently  in  an  epidemic  and  malignant  form.  In  Africa  it 
is  not  wanting.  It  prevailed  extensively  among  the  British  troops 
in  the  Zulu,  Egyptian,  and  Soudan  campaigns,  and  among  the 
French  troops  in  Tunis.  Brigade-Surgeon  Albert  A.  Gore,  M.D., 
contributed  to  the  Dublin  Journal  of  Medical  Science  a  series  of 
papers  on  enteric  fever  in  Egypt  since  the  British  occupation  of 
that  country. 

In  North  America  the  disease  is  endemic  from  Greenland  to 
Mexico.  It  has  been  observed  throughout  Central  and  South 
America  also,  as  well  as  in  most  parts  of  Australasia. 

./Etiology. — General  considerations  lead  us — for  the  most  part 
with  Murchison — to  the  following  conclusions  : — 

1.  Enteric  fever  is  either  an  endemic  disease,  or  its  epidemics 
are  circumscribed  (and  local). 

2.  It  is  most  prevalent  in  autumn  and  after  warm  weather. 

3.  It  is  independent  of  overcrowding,  and  attacks  rich  and  poor 
indiscriminately. 

4.  It  sometimes  arises  apparently  independently  of  a  previous 
case,  in  the  presence  of  fermentation  of  faecal  and  perhaps  other 
forms  of  organic  matter,  in  which  presumably  the  "  resting  spores  " 
of  its  conlagium  vivum  have  lurked. 

5.  It  may  be  communicated  by  the  sick  to  persons  in  health,  but 
even  then  the  poison  is  not  like  smallpox,  given  off  from  the  body 
in  a  virulent  form,  but  is  developed  by  the  decomposition  of  the 
excreta  after  their  discharge. 

Dr.  Cayley  expresses  the  opinion — based  upon  observations  made 
at  the  Middlesex  Hospital — that  the  period  required  for  the 
development  of  the  infectious  properties  of  the  stools  in  this  fever 
does  not  exceed  twelve  hours,  and  may  be  shorter.  He  holds  that 
the  fresh  stools  are  incapable  of  communicating  the  disease,  a  point 
which  may  well  be  regarded  as  settled,  notwithstanding  the 
opinion  to  the  contrary  put  forward,  in  1880,  by  Dr.  Collie,  of  the 
Homerton  Fever  Hospital. 

6.  Consequently,  an  outbreak  of  enteric  fever  implies  poisoning 
of  air,  drinking  water,  milk,  or  other  ingesta,  with  decomposing 
excrement. 


346  ENTERIC   FEVER. 

I  have  ventured  to  change  the  wording  of  the  fourth  of  these 
propositions,  because  I  cannot  •assent  to  the  doctrine  of  the  de 
novo  or  spontaneous  origin  of  enteric  fever  which  is  implied 
in  Murchison's  original  words — viz.,  "  It  may  be  generated  inde- 
pendently of  a  previous  case  by  fermentation  of  faecal,  and,  per- 
haps, other  forms  of  organic  matter."  a 

While  we  admit  the  propriety  of  using  the  term  "  endemic  "  in 
connection  with  enteric  fever,  we  agree  with  Dr.  Hilton  Fagge 
that  "  there  could  be  no  greater  mistake  than  to  suppose  that  its 
diffusion  is,  like  that  of  ague,  independent  of  the  movements  of 
human  beings  and  of  their  intercourse."  The  analogy  is  rather 
between  enteric  fever  and  cholera. 

Of  late  years  enteric  fever  has  shown  a  greater  tendency  to  an 
epidemic  prevalence  than  was  formerly  the  case.  This  is  notably 
so  in  Dublin,  where  an  epidemic  of  this  fever  has  prevailed  every 
autumn  since  1887.  The  Registrar-General  for  Ireland,  Dr. 
Grimshaw,  has  furnished  me  with  accurate  statistical  facts  bearing 
upon  the  prevalence  of  both  typhus  and  enteric  fever  in  Dublin 
during  the  past  twelve  years.  From  Table  II.,  in  which  this  infor- 
mation is  embodied,  the  rapid  decline  of  typhus  and  the  still  more 
rapid  increase  of  enteric  fever  in  the  Irish  metropolis  are  clearly 
apparent.  The  Table  includes  the  number  of  cases  of  typhus  and 
of  enteric  fever  admitted  to  hospital  each  quarter  and  of  deaths 
from  these  diseases  in  the  Dublin  Registration  District  during  the 
twelve  years,  1879-1890,  inclusive. 

a  Murchison.     Loc  cit.     1884.     Page  499. 


Table  II. — Showing  for  each  Quarter  in  the  12  years,  1879-90,  the  number 
of  cases  of  Typhus  and  of  Enteric  Fever  admitted  into  the  principal  huh1  in. 
hospitals  ;  the  number  of  Deaths  in  these  Institution*  from  each  of  the 
diseases  named,,  and  the  number  of  Deaths  from  those  causes  registered  in, 
the  whole  of  the  Dublin  Registration  District. 


Years 

Quarters 

Typhus 

Enteric  Fever 

No. 

of 

Admissions 

to 

Hospitals 

Deaths 

in 

Hospitals 

Total 

Deaths 

Registered 

in 

Dublin 

Registration 

District 

No. 

of 

Admissions 

to 
Hospitals 

Deaths 

in 

Hospitals 

Total 

Deaths 

Registered 

in 

Dublin 

Regist  ratio' 

District 

1879 

March 

70 

16 

25 

143 

21 

83 

June 

57 

13 

20 

72 

8 

51 

September 
December 

43 
49 

9 
6 

21 

23 

71 
81 

2 
5 

34 

37 

Total 

219 

44 

89 

367 

36 

205 

1880 

March 

159 

19 

26 

94 

11 

47 

June 

129 

32 

44 

67 

4 

63 

September 
December 

141 
470 

21 
44 

32 
55 

107 
109 

4 

4 

32 
46 

Total 

899 

116 

157 

377 

23 

188 

1881 

March 

470 

72 

85 

51 

7 

42 

June 

357 

42 

54 

35 

2 

28 

September 
December 

246 
147 

31 
18 

36 
19 

31 
52 

6 
7 

31 
22 

Total 

1,220 

163 

194 

169 

22 

123 

1882 

March 

126 

19 

25 

34 

3 

28 

June 

96 

16 

19 

44 

2 

33 

September 
December 

124 
245 

11 

18 

17 
23 

49 
75 

2 
2 

29 
45 

Total 

591 

64 

84 

202 

9 

135 

1883 

March 

351 

51 

57 

42 

3 

46 

June 

253 

28 

48 

30 

3 

27 

September 
December 

100 
125 

17 

9 

23 
13 

34 
76 

3 

9 

26 
33 

Total 

829 

105 

141 

182 

18 

132 

1884 

March 

141 

22 

30 

64 

8 

29 

June 

122 

20 

21 

48 

3 

29 

September 
December 

103 
103 

9 
14 

12 

20 

34 

72 

6 
12 

30 

46 

Total 

469 

65 

83 

218 

29 

134 

Table  IT. — continued. 


1885 


1886 


1887 


1888 


Quarters 


1889 


1890 


March 
June 

September 
December 

Total 


March 
June 

September 
December 


No. 

of 

Admissions 

to 
Hospitals 


Deaths 
in 

Hospitals 


Total 


March 
June 

September 
December 

Total 


March 
June 

September 
December 

Total 


March 
June 

September 
December 

Total 


March 
June 
September 
December 

Total 


78 
70 
54 
45 

247 


38 
16 
38 
31 

123 


33 
32 
28 

42 

135 


51 
27 
21 

179 


46 
24 
27 
35 

132 


48 
36 
14 
61 

159 


Total 

Deaths 

Registered 

in 

!  Dublin 

Registration 

District 


Enteric  Fever 


No. 

of 

Deaths 

Admissions 

in 

to 

Hospitals 

Hospitals 

Duul'n 

Registration 

District 


15 

14 
6 
4 

39 


9 
3 

7 
3 

22 


14 


7 
3 
5 
5 

20 


4 
3 
3 

18 


5 
5 

1 
9 

20 


17 

17 

14 

6 

54 


18 

4 

11 


39 


5 

10 

5 

4 

24 


9 

7 

5 

10 

31 


7 
5 
3 
3 

18 


25 


58 
48 
73 
86 

265 


75 

32 

55 

101 

263 


65 

57 
75 
79 

276 


65 

39 

91 

170 

365 


126 
127 
176 
354 

783 


4 

155 

7 

135 

2 

106 

12 

240 

636 


3 
5 

5 
9 

22 


9 

4 

7 

15 

35 


28 


5 
25 

44 


12 
13 
16 

38 

79 


23 

8 

16 

19 

66 


1600 

7600 

_ 

PI 

1500 

/500 

„ 



14-00 

14-00 



J300 

1300 



. 

izoo 

:':...; 

i^il 

noo 

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— 

II II     |j       1 1 



woo 

1  1 

7006 

7- 

900 

1 1 H 

9C0 

— 

800 

1  i 

Stf0 



100 

1 1 

100 

600 

II  ji  mmmt 

600 



nil     1 

WO 

I j  f|| 

500 

— 

1 



100 

1 

too 

— 

300 

1     I   1      I 

300 



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ZOO 

li  ||     1              H     I 

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Diagram,  C shows  the  Ayes  of 59 J  I  cases  of  Enteric  Fever,  admitted/  irvbo  the  Londorv 
Fever  Hospital,  with  the  number  of  Deaths  MM  at  each  age.  (Compare  wtihDLcucfr.  A  J 


ENTERIC    FEVER.  349 

Predisposing  Causes : — 

1.  Sex  has  little  or  no  influence  in  determining  the  occurrence 
of  this  disease.  Of  5,988  patients  admitted  into  the  London 
Fever  Hospital  in  the  23  years,  1848-70,  3,001  were  males  and 
2,987  were  females — a  difference  of  only  14  in  favour  of  the  male 
sex. 

2.  Age  is  a  more  potent  predisponent,  Of  5,911  cases  in  the 
London  Fever  Hospital,  3,926,  or  64*71  per  cent,  were  between 
10  and  24  years  of  age.  Enteric  fever  is  a  disease  of  youth  and 
adolescence,  the  mean  age  of  1,772  cases  being  21-25  years 
(Murchison).  The  influence  of  age  is  illustrated  in  Diagram  C, 
from  Murchison's  work. 

3.  Defective  Sewerage  and  Drainage. — In  the  United  Kingdom, 
as  well  as  in  France,  Germany  and  America,  enteric  fever  has 
increased  in  the  presence  of  shortcomings  in  sanitation. 

4.  Season. — This  fever  is  most  prevalent  in  autumn  and  early 
winter — hence  the  names  by  which  it  is  often  described  in 
America — "Autumnal,"  or  "Fall  Fever."  The  exciting  cause 
of  the  disease  seems  to  be  called  into  action  only,  as  Murchison 
says,  "  by  the  protracted  heat  of  summer  and  autumn,  while  it 
required  the  protracted  cold  of  winter  and  spring  to  impair  its 
activity  or  to  destroy  it."  An  examination  of  the  returns  of  the 
Registrar-General  for  Ireland  shows  that  enteric  fever  exhibits  — 
as  the  summer  rolls  by — a  decided  tendency  to  increase  in  Dublin 
at  an  earlier  period  than  typhus.  This  is,  no  doubt,  partly  due  to 
the  fact  that  the  secondary  phenomena  of  enteric  fever  are  gene- 
rally developed  in  connection  with  the  digestive  system,  acute  and 
infective  diseases  of  which  increase  towards  autumn. 

The  accompanying  Diagram  (4)  is  reproduced  from  the  Annual 
Summary  of  the  Registrar-General  for  England  for  1890. 

5.  Temperature  and  Moisture. — Hot,  dry.  calm  summers  increase 
the  prevalence  of  enteric  fever,  which  is  less  frequent  in  cold,  wet, 
stormy  seasons.  Warm,,  damp  weather,  however,  predisposes  to  the 
disease.  Floods  occurring  in  badly-drained  localities  may  impreg- 
nate sources  of  drinking  water  with  the  germs  of  enteric  fever,  and 
so  lead  to  its  outbreak. 


350  ENTERIC   FEVER. 

6.  Soil  and  Underground  Water. — Professor  von  Pettenkofer 
and  Professor  P»uhl,a  of  Munich,  have  shown  that  when  the  subsoil 
water  in  that  city  (as  measured  by  the  depth  of  water  in  the  sur- 
face wells)  is  falling,  the  number  of  cases  of  enteric  fever  increases  ; 
when  the  water  level  is  rising,  the  number  of  cases  diminishes. 
Liebermeister  and  Buchanan  suppose  that  these  observations  simply 
illustrate  ihe  mode  in  which  the  disease  is  communicated  by  means 
of  drinking  water.  When  the  subsoil  water  is  low  any  noxious 
matters  in  it  accumulate  and  acquire  a  greater  virulence. 

In  the  case  of  an  outbreak  of  enteric  fever  at  Terling,  Essex,  in 
December,  1867,  Dr.  Thorne  Thorne,  Inspector  of  the  Local 
Government  Board  of  England,  found  that  the  disease  had  broken 
out  with  great  severity  precisely  when  the  wells  were  high.b 

7.  Idiosyncrasy. — Many  facts,  says  Murcliison,  "  seem  to  show 
that  certain  peculiarities  of  constitution  favour  or  avert  an  attack  " 
of  enteric  fever. 

8.  Recent  Residence  in  an  infected  locality  is  universally 
admitted  to  be  a  powerful  predisponent  to  enteric  fever.  It 
would  seem  that  the  system  through  constant  exposure  becomes 
habituated  to  the  effects  of  the  poison,  and  in  this  respect  enteric 
fever  resembles  dysentery,  ague,  and  other  malarious  fevers. 

Besides  Age — Occupation,  Station  in  Life,  Overcrowding  and 
Defective  Ventilation,  Previous  Illness,  Intemperance,  Fatigue,  and 
Mental  Emotions — all  seem  to  have  little  or  no  determining  influence 
in  increasing  the  liability  to  enteric  fever. 

Immunity. — As  a  general  rule,  one  attack  of  enteric  fever  pro- 
tects its  subject  from  a  second.  At  the  same  time  well-authenti- 
cated instances  of  persons  contracting  this  fever  a  second  time 
are  on  record.  Several  have  come  under  Murchison's  notice,  in 
which  both  attacks  have  occurred  subsequent  to  puberty.  Trous- 
seau records  two  examples  of  a  second  attack — one  patient,  a  woman, 

a  An  excellent  resume"  of  various  papers  on  this  subject  in  the  Zeitschriftfiir 
Biologie  will  be  found  in  the  Uffeskrift  for  Lceger,  Copenhagen,  January  30, 
1869.  A  translation  by  my  father,  Dr.  W.  D.  Moore,  appeared  in  the  Dubl. 
Journ.  of  Med.  Science.     Vol.  XLVII.,  p.  497.     May,  1869. 

b  Tenth  Repvrt  of  the  Medical  Officer  of  the  Privy  Council.     1868.     Page  51. 


ENTERIC   FEVER.  351 

suffered  again  after  an  interval  of  four  years  ;  the  other,  a  girl,  had 
a  severe  attack  at  the  age  of  twelve,  and  another  equally  severe  a 
year  afterwards.  Similar  instances  of  unequivocal  second  attacks 
have  been  recorded  by  Piedvache,  Michel,  Bartlett,  Paul,  and 
William  Budd.a 

In  April,  1877, 1  attended  with  the  late  Dr.  Alfred  Hudson,  a  lad 
of  fifteen  years,  who  passed  through  a  typical  attack  of  enteric 
fever  lasting  23  days — in  which,  however,  constipation  and  not 
diarrhoea  was  the  rule.  In  October,  1891,  the  same  gentleman,  at 
the  age  of  twenty-nine,  sickened  of  a  fever  which  proved  to  be  un- 
doubted enteric  fever.  The  Charts  in  both  illnesses  are  included  in 
Plate  IX. 

Exciting  Cause. — This  is  the  introduction  into  a  susceptible 
body  of  the  specific  virus  of  Enteric  Fever. 

Bacteriology. — That  parasitic  organisms,  capable  of  self-repro- 
duction, lie  at  the  root  of  the  toxic  agent  or  that  they  are  essen- 
tially related  thereto,  has  long  been  conjectured,  for  that  toxic 
agent  is  capable  of  reproduction  to  an  extraordinary  degree  both 
within  and  without  the  human  body.  Furthermore,  the  disease 
shows  a  course  which  is  strikingly  typical,  appearing  as  it  does  to 
be  dependent  upon  the  phases  of  development  of  such  a  Contagium 
vivum  (Zuelzer ). 

The  fullest  accounts  of  recent  researches  into  the  micro-parasitic 
origin  of  enteric  fever  will  be  found  in  Dr.  Gaffky's  article  on  the 
"Etiology  of  Enteric  Fever,"  which  appeared  in  the  second  volume 
of  Mittheilungen  aus  dem  Gesundheitsamte  (Berlin,  1884),  and  was 
translated  for  the  New  Sydenham  Society,  by  Mr.  J.  J.  Pringle, 
M.B.,  Assistant  Physician  to  the  Middlesex  Hospital;6  and  in  Mr. 
Watson  Cheyne's  translation  for  the  same  Society  of  Micro-organisms 
with  Special  Reference  to  the  Etiology  of  the  Infective  Diseases,  by  Dr. 
C.  Flugge,  O.  O.  Professor  and  Director  of  the  Hygienic  Institute 
at  Gottingen.c 

a  See  Murchison.     Loc.  cit.     Third  Edition.     1884.     Page  471. 

b  The  New  Sydenham  Society.  Vol.  CXV.,  page  205,  et  seq.  London  : 
H.  K.  Lewis.    1886. 

c  The  New  Sydenham  Society.  Vol.  CXXXII.,  page  248,  et  scq.  London  : 
H.  K.  Lewis.     1890. 


352  ENTERIC   FEVER. 

So  long  ago  as  the  year  1870,  a  communication  was  made  by- 
Coze  and  Feltz  that  they  had  found  in  the  blood  of  typhoid  patients 
an  organised  ferment,  the  shape  of  which  recalled  that  of  Bacterium 
catenula. 

The  earliest  fruitful  investigations  on  the  subject  were  those  by 
von  Recklinghausen  in  1871,  Eberth  in  1872,  and  Klein  a  in  187o. 
The  first  real  advance  was  made,  however,  in  1880,  when  Eberth 
discovered  a  characteristic  micro-parasite  in  the  implicated  viscera 
of  enteric  fever.b  To  this  the  name  Bacillus  typhosus  (Eberth) 
was  given.  About  the  same  time  similar  observations  were  made 
by  Klebs  and  Ef>pinger,c  and  these  have  been  confirmed  by  the 
researches  of  Robert  Koch,  Meyer,  and  Friedlander,  and  more 
recently  by  Gaffky  and  very  many  others  (von  Jaksch) — in  our 
own  country,  by  Coats  and  Crooke.d 

Gaffky  conducted  a  series  of  most  accurate  investigations  on  the 
subject  in  the  laboratory  of  the  Imperial  Office  of  Public  Health, 
Berlin,  with  the  result  that,  in  twenty-six  out  of  twenty-eight  fatal 
cases  of  enteric  fever  examined,  the  typical  bacillar  masses  were 
present  in  the  mesenteric  glands,  or  in  the  spleen,  liver,  or  kidneys. 
From  this  fact  Eberth  considers  that  the  view  that  these  organisms 
are  in  reality  the  cause  of  the  typhoid  process,  has,  without  question, 
increased  in  probability  to  a  high  degree.  Moreover,  the  bacilli 
do  not  apparently  proliferate  after  death,  as  they  would  do  had 
they  anything  to  say  to  putrefaction.  When  animals  have  been 
infected  by  inoculation  with  these  bacilli,  they  manifest  symptoms 
of  enteric  fever,  and  the  researches  of  E.  Frankel,  M.  Simmonds,e 
and  C.  Seitz,f  seem  to  leave  no  doubt  as  to  their  pathogenic 
character,  although  Beumer  and  Peiper g  have  come  to  a  different 

8  Reports  of  the  Medical  Officer  of  the  Privy  Council  and  Local  Government 
Board.     London.     1875. 

b  Virchows  Archiv.     LXXXIII.,  486.     1881. 

c  Klebs'  Bandbuch  der  pathol.  Anatomie,  7  Leiferung,  bearbeitet  von  Prof. 
Eppinger. 

d  Brit.  Med.  Journal,  March  12  and  July  1,  1882. 

e  Centralbl.  fur  klin.  Med.     VI.,  737.     1885. 

f  Bacterial.  Studien  z.  Typhus-atiologie.     Munich.     1886. 

e  Zeitschrift  jur  Hygiene,  I.,  489,  1886,  and  II.,  110,  1887. 


ENTERIC    FEVER.  3f>3 

conclusion.  Gaffky  has  not  succeeded  in  producing  the  disease 
in  animals  with  his  cultivations. 

Bacilli  have  of  late  years  repeatedly  been  found  in  the  blood  of 
typhoid  patients,  and  von  Jaksch  a  says  "  they  are  doubtless  the 
exciting  cause  of  the  disease."  Rutimeyerb  and  Neuhaus0 
experimented  upon  the  blood  taken  from  the  rose-spots,  and 
succeeded  in  cultivating  bacilli  from  it. 

Bozzolo,d  in  three  atypical  cases,  was  able  to  demonstrate  the 
presence  of  Eberth's  bacillus  in  the  blood,  and  thus  determine  that 
he  was  dealing  with  typhoid  septicaemia.  He  considers  bacterio- 
logical examination  of  the  blood  of  great  diagnostic  importance. 

Neumann, e  again,  has  found  the  Bacillus  typhosus  in  the  urine  in 
six  out  of  twenty-three  cases  investigated.  Karlinski,  of  Cracow, 
examined  the  kidneys  and  urine  in  six  fatal  cases  of  enteric  fever 
and  the  urine  in  thirty-eight  other  cases  of  the  same  disease. 
Bacilli  were  found  in  all  the  kidneys  examined.  In  twenty-one 
specimens  of  urine  Eberth's  bacilli  were  found,  all  these  urines 
being  albuminous.  When  albuminuria  was  transient  or  absent, 
no  bacilli  were  found.  Colonies  rapidly  increased  in  albuminous 
urine,  and  preserved  their  vitality  for  a  long  period ;  in  urine 
containing  bile,  the  bacilli  died  in  five  days. 

An  important  question  arises  as  to  the  passage  to  the  foetus 
from  the  mother  of  the  micro-organisms  of  enteric  fever.  Eberth 
in  particular  has  raised  an  objection  to  the  experiments  made  by 
Reher,  Nenhaus,  Chantemesse,  and  Vidal,f  which  went  to  demon- 
strate the  presence  of  the  Bacilli  typhosi  in  the  blood  of  foetuses 
derived  from  typhoid  mothers.  Eberth  is  of  opinion  that  a  confu- 
sion must  have  arisen  between  the  bacteria  of  typhoid  and  the 
bacteria  of  putrefaction.      In  one  of  his  later  communications,8 

a  Clinical  Diagnosis.  Translated  by  James  Cagney,  M.D.  London  :  Charles 
Griffin  &  Co.     1890.     Page  33. 

b  Centralbl.  fur  klin.  Med.     VIII.,  145.     1887. 

c  Berlin,  med.  Wochensch.     XXIII.,  89  and  389.     1886. 

d  Deutsche  med.  Zeitung.  Berlin.  Aug.  28,  1890.  Sajous'  Annual  of  the 
Universal  Medical  Sciences.     1891.     Vol.  I.,  H.-52. 

e  Berlin,  med.  Wochensch.     XXV.,  Nos.  7-9.     1888. 

f  Recherches  sur  le  bacille  typhique  et  I'etiologie  de  la  filvre  typhoide.  Wiirz- 
burg.     1888. 

'  Centralblatt  fiir  die  med.  Wissensch.     1889.     Juni  1. 

2   A 


354  ENTERIC    FEVKR. 

however,  Eberth  admits  the  correctness  of  the  observations;  and 
still  more  recently,  Dr.  Joseph  Giglio,a  of  Palermo,  in  an  original 
paper,  entitled  "  Ueber  den  Uebergang  der  mikroskopischen  Organ- 
ismen  des  Typhus  von  der  Mutter  zum  Fotus,"  as  a  result  of  his 
experiments,  comes  to  the  conclusion  that  the  bacillus  cultivated 
by  him  is  the  genuine  Bacillus  typhosus.  To  confound  it  with 
saprophytes  is  out  of  the  question. 

Gaffky's  results  agree  entirely  with  the  descriptions  given  by 
Eberth,  Koch,  and  Meyer  in  regard  to  the  shape  and  appearance  of 
the  bacilli.  On  the  average  the  rods  are  about  thrice  as  long  as 
they  are  broad ;  their  length  corresponds  to  about  the  third  part  of 
the  diameter  of  a  red  blood  corpuscle.  The  rods  are  2  fi.  broad,  and 
form  filaments  up  to  50  /*.  long.  In  isolated  spots  one  may  see 
somewhat  longer  threads,  which  on  more  thorough  examination  are 
seen  to  be  made  up  of  several  segments.  The  extremities  of  the 
bacilli  are  distinctly  rounded  off.  In  several  of  the  cases  examined 
by  Gaffky,  the  bacilli  found  in  the  internal  organs  contained 
unmistakable  spores,  which  appeared  as  round  portions,  remaining 
unstained  and  occupying  the  whole  breadth  of  the  bacilli. 

The  Bacillus  typhosus  occurs  in  the  stools  of  enteric  fever,  but  it 
is  impossible  to  recognise  it  with  the  microscope  alone,  owing  to' 
the  vast  number  of  microbes  constantly  to  be  found  in  the  dejec- 
tions of  this  disease.  Nor  does  it  stain  well  for  diagnostic  purposes. 
Hence  it  is  necessary  to  obtain  pure  cultivations  for  its  complete 
recognition. 

The  difficulty  of  staining  this  organism,  and  its  occurrence  in 
solitary  isolated  clumps,  enabled  it  for  a  long  time  to  elude  the 
vigilance  of  observers.  In  connection  with  this,  Dr.  German  Sims 
Woodhead  mentions  a  plan  which  may  prove  useful  to  inquirers. 
"  These  bacilli,''  he  writes,6  "  are  said  to  be  stained  with  difficulty, 
but  I  have  found  that  if  the  sections  in  which  they  are  present  are 
first  allowed  to  remain  for  about  ten  minutes  in  a  one-fifth  per  cent, 
solution  of  corrosive  sublimate,  and  then  stained  by  Gram's  method, 
the  bacilli  are  most  deeply  stained,  although   Frankel  and  other 

a  Centra'blatt  fii>-  Gynacohgie.     1890.     No.  46,  page  819. 

a  Bacteria  and  their  Products.     London  :  Walter  Scott.     1891. 


ENTERIC   FEVER.  355 

observers  state  that  the  colour  is  invariably  discharged  if  Gram's 
method  be  used."  This,  however,  is  only  part  of  the  difficulty,  for 
although  the  bacilli  are  found  in  clumps  in  the  adenoid  follicles,  in 
the  spleen,  and  commonly  in  the  mesenteric  glands,  it  is  only,  as 
Fliigge  says,  "  after  the  examination  of  a  large  number  of  sections 
that  one  or  several  of  these  follicles  can  be  found." 

The  Bacillus  typhosus  develops  readily  in  a  medium  of  nutrient 
gelatin — the  cultivations  appearing  after  twenty-four  hours.  Rods 
and  threads  appear  under  the  microscope,  and  they  seem  to  be 
endowed  with  an  evident  and  peculiar  motion.  The  parasite 
develops  to  an  extraordinary  extent  on  prepared  potato  at  a  tempera- 
ture of  37°  C.  (98-6°  Fahr.).  Spores  form  after  three  or  four 
days.  On  microscopical  examination  the  inoculated  mobile  bacilli 
are  found  in  surprising  abundance.  The  whole  surface  seems  to 
consist  almost  entirely  of  bacilli,  which  stain  only  with  moderate 
intensity  with  aniline  dyes.  A  globulin  substance,  behaving  like 
myosin,  seems  to  be  the  nutrient  material  in  the  potato.  Typhoid 
bacilli  also  grow  luxuriantly  on  sterilised  blood  serum  of  sheep,  in 
solidified  blood  serum  around  punctures  made  with  the  platinum 
needle,  in  meat  infusion,  as  well  as  in  some  vegetable  infusions 
(Gaffky). 

A  discussion  has  lately  taken  place  as  to  the  mode  of  origin  of 
enteric  fever  in  India  and  other  tropical  and  subtropical  climates, 
and  is  referred  to  by  Dr.  Cayley  in  the  Third  Edition  of  Murchi- 
son's  Treatise  on  the  Continued  Fevers.  In  this  discussion  there 
seemed  to  be  a  general  consensus  of  opinion  that  the  disease  may 
arise  de  novo,  and  two  theories  were  put  forward  as  to  the  mode  of 
origin — the  entogenous  and  the  ectogenous.  The  former  theory 
implies  that  the  disease  may  be  generated  in  the  system,  without 
any  infection  from  outside  the  body,  from  the  effects  of  climate, 
changed  modes  of  life,  or  even  the  decomposition  of  fasces  in  the 
intestinal  canal.  This  apparent  mo'de  of  origin  I  myself  long  since 
recognised,  chiefly  in  relation  to  retention  and  decomposition  of  the 
faeces  in  the  bowels,  but  I  prefer  the  term  "  autogenous  "  or  perhaps 
"  autochthonous,"  to  "  entogenous,"  as  an  adjectival  prefix  to 
enteric  fever  arising  in  this  way. 


356  ENTERIC    FEVER. 

However,  since  the  discovery  of  Eberth's  Bacillus  typhosus,  and. 
the  establishment  of  its  causal  relation  to  enteric  fever,  the  doc- 
trine of  the  de  novo  or  spontaneous  origin  of  the  disease,  whether 
without  (pythogenic)  or  within  (autogenic)  the  body,  has  become 
untenable. 

My  opinions,  therefore,  have  of  necessity  been  modified,  and  the 
doctrine  I  now  hold  is  this — Enteric  fever  arises  only  when  the 
spores  of  the  specific  microbe  already  named  enter  the  body,  and 
especially  the  intestinal  canal,  of  a  susceptible  individual. 

But  the  state  of  health  which  accompanies  habitual  constipation, 
with  fgecal  decomposition  in  the  intestines  the  result  of  that  consti- 
pation, enormously  increases  the  susceptibility  of  an  individual, 
and,  in  fact,  acts  so  powerfully  as  a  predisposing  cause  as  almost  to 
appear  to  be  the  exciting  cause  of  an  attack  of  the  disease. 

I  believe  that  under  such  circumstances  a  very  minute  dose  of 
the  specific  poison  will  suffice  to  kindle  an  attack  of  enteric  fever, 
which  might  consequently  seem  to  be  of  independent  or  spontaneous 
origin — to  be,  in  a  word,  autogenous  or  autochthonous.8. 

Enteric  fever  probably  arises  in  the  following  way: — The 
specific  bacilli,  or  rods,  form  spores  inside  the  organs  of  one 
sick  of  the  disease,  especially  in  the  mucous  membrane  of  the 
small  intestine.  The  micro-organisms  are  then  discharged  with 
the  motions  in  their  most  resistant  condition — i.e.,  as  resting 
spores — and  thus  pass  into  faulty  or  leaky  drains  or  cesspools,  or 
into  the  ground.  In  these  situations  they  may  remain  quiescent, 
and  therefore  harmless,  for  a  long  time  for  want  of  suitable 
nourishment  or  of  a  suitable  temperature.  At  last  these  resting 
spores  arrive  by  chance  in  a  body  capable  of  being  infected,  and 
there  they  develop  into  bacilli,  and  begin  anew  their  cycle  of 
existence  as  pathogenic  microbes.  Gaffky  further  shows  that  it  is 
highly  probable  that  the  development  of  the  spores  does  not  occur 

a  These  several  terms  are  derived  from  the  Greek,  namely  : — 

"Entogenous,"  from  ivrSs,  within;  yevvdw,  I  beyet  or  produce. 

"  Ectogenous,"  from  £kt6s.  without;  ynvvdw. 

"Autogenous,"  from  avros,  srtf ;  yevvdoi. 

"  Autochthonous,"  from  o.vt6x6o»/,  sprung  from  the  soil  itself  {L&t.  terrigena), 
indigenous.     From  avr6s,  self ;  x^v>  the  earth,  ground. 


ENTERIC    FEVER. 


857 


only  in  the  human  organism,  but  that — as  in  case  of  the  bacilli  of 
splenic  fever  (Bacillus  anthracis) — they  may  sprout  and  form  bacilli 
in  favourable  circumstances  even  outside  the  animal  economy,  in- 
creasing enormously  in  numbers,  and  in  the  warmer  part  of  the 
year  forming  spores  afresh. 

Paths  of  Infection. — In  Gaffky's  opinion— and  he  is  no  doubt 
correct  in  his  view — the  most  diverse  paths  stand  open  to  the 
infecting  germs  for  admission  into  the  human  organism,  and  it 
would  be  one-sided  to  fix  one's  attention  solely  on  one  or  another 
of  these.  Besides  the  air  which  we  breathe,  and  the  water  which 
we  drink,  our  food  may  be  the  carrier  of  the  typhoid  virus. 

I.  The  poison  maybe  transported  by  currents  of  air.  Murchison 
cites  remarkable  instances  of  such  an  occurrence — outbreaks  of 
enteric  fever  having  been  caused  by  exhalations  from  drains,  or 
sewers,  or  water-closets.  Such  outbreaks  took  place  at  the  Peckham 
police  station  in  1859,  at  Chatham  in  1872,  in  the  School  and 
Abbey  Cloisters  at  Westminster  in  1848,  and  at  a  school  at 
Clapham  in  August,  1879.  Under  these  and  similar  circumstances 
pneumonic  fever,  called  by  Dr.  T.  W.  Grimshaw  and  me  "  Pytho- 
genic  Pneumonia,"  a  is  also  apt  to  arise. 

II.  The  poison  may  be,  and  probably  most  usually  is,  conveyed 
by  drinking  water.  Of  this  Dr.  Hilton  Fagge  specifies  not  fewer 
than  1 1  very  striking  and  conclusive  examples.  The  most  singular 
of  these  was  an  outbreak  at  Lausen  in  the  Valley  of  Ergolz  in  the 
Jura  in  August,  1872,  when  130  out  of  a  population  of  about  800 
people  were  attacked,  all  of  whom  used  the  water  of  a  public 
fountain,  fed  from  two  sources.  One  of  these  was  a  spring  into 
which  water  percolated  from  certain  meadows  in  another  valley, 
separated  from  the  Ergolz  Valley  by  a  mountain,  the  Stockhalder. 
In  that  other  valley  two  cases  of  enteric  fever  occurred  in  July, 
1872.  The  discharges  from  the  patients  were  thrown  into  an 
adjoining  stream.  In  the  middle  of  the  month  just  named  the 
water  of  this  stream  was  used  to  irrigate  the  meadows,  and  three 
weeks  later  the  epidemic  at  Lausen  began. 

fl  Dull.  Journ.  of  Med.  Science.     1875.     Vol.  LIX.,  page  399. 


358  ENTERIC  FEVER. 

III.  Milk  may  be  contaminated  with  the  poison,  and  when 
used  may  give  rise  to  the  disease. 

The  first  epidemic  traced  to  such  an  origin  occurred  in  Islington 
in  1870,  and  was  investigated  by  Dr.  Edward  Ballard.  Similar 
outbreaks  took  place  at  Armley,  near  Leeds,  in  the  summer  of  1872, 
and  in  the  St.  Marylebone  District,  London,  in  the  summer  of  1873. 
About  Christmas,  1878,  a  remarkable  epidemic  was  caused  by 
infected  milk  in  the  Pembroke  Township,  Dublin.  This  was 
thoroughly  investigated  by  Sir  Charles  Cameron,  who  published  an 
excellent  account  of  it  in  the  Dublin  Journal  of  Medical  Science  for 
July,  1879  (Vol.  LXVIII.,  No.  91,  Third  Series).  All  the  house- 
holds affected  were  supplied  with  milk  from  a  particular  dairy,  the 
owner  of  which  had  been  ill  with  "  fever  "  since  the  middle  of 
December.  Two  children  had  also  been  ill  with  fever  of  some  kind 
during  the  same  month,  and  all  the  patients  had  remained  in  a 
small  house  attached  to  the  dairy.  The  excreta  were  daily  thrown 
out  on  a  dung-heap  close  to  the  cow-sheds,  and  the  milk-pails 
were  so  placed  that  they  could  hardly  escape  being  infected  by 
means  of  particles  of  matter  from  the  dung-heap  carried  by  the 
wind. 

The  bibliography  of  milk-epidemics  of  enteric  fever  is  rapidly 
increasing. 

In  the  "  Transactions  of  the  Second  Intercolonial  Medical  Con- 
gress of  Australasia,"  Dr.  Allen  records  the  occurrence  of  an  out- 
break at  Melbourne  in  the  spring  of  1879.  The  son  of  a  milkman 
died  of  enteric  fever.  Of  93  households  supplied  with  milk  by  the 
milkman  in  question,  23  were  visited  by  enteric  fever.  Forty 
persons  were  attacked,  of  whom  3  died.  In  the  middle  of  June, 
1889,  enteric  fever  suddenly  appeared  in  a  community  of  3,000 
inhabitants  in  Sweden.  One  hundred  and  four  cases  with  11 
deaths  occurred  in  less  than  four  months.  It  was  discovered  that 
those  attacked  received  their  milk  from  the  same  dairy.  The  milk 
was  gathered  from  various  sources  and  redistributed.  Two  persons 
ill  of  fever,  presumably  typhoid,  were  probably  the  starting  point 
of  the  outbreak. 

In  the  Edinburgh   Medical  Journal  for  1890-91  (Vol.  XXXVL, 


ENTERIC    FEVEK.  359 

pages  801-814),  Dr.  H.  Littlejohn  reports  an  outbreak  of  typhoid 
fever  due  to  milk  infection. 

To  the  American  Lancet,  Detroit,  1891  (New  Series,  XV.,  pages 
121-128),  E.  P.  Christian  contributes  a  paper,  entitled  "Cows' 
Milk  and  Typhoid  Fever." 

In  1890,  A.  Vincent a  published  a  "Note  sur  une  ^pid^mie  de 
fievre  typho'ide  propag^e  par  le  lait." 

IV.  There  is  some  reason  to  believe  that  meat  may,  under 
exceptional  circumstances,  convey  the  poison  of  enteric  fever. 
Dr.  Cayleyb  states  that  several  outbreaks  from  this  cause  have 
been  reported  from  Switzerland,  where  cattle  are,  according  to 
Huguenin,c  not  uncommonly  affected  by  true  enteric  fever.  The 
most  remarkable  outbreak  of  this  kind  was  one  which  took  place  at 
Kloten,  near  Zurich,  in  1878.  Upwards  of  700  persons  were  attacked 
in  consequence  of  eating  decomposed  veal  from  a  calf,  which 
Huguenin  believes  to  have  been  affected  by  enteric  fever. 

Legrain  {Ann.  de  la  Policlin.  de  Paris,  October,  1891,  and  Brit. 
Med.  Journ.,  November  7,  1891)  says  that  the  problem  of  the 
origin  and  propagation  of  enteric  fever  is  probably  solved  by  the 
discovery  of  Eberth's  bacillus  and  by  the  finding  of  this  micro- 
organism in  the  water  suspected  of  conveying  the  disease,  Three 
theories  have  been  put  forward — (1)  autotyphisation,  and  the 
identity  of  the  B.  coli  communis  with  Eberth's  bacillus  lends  some 
strength  to  this  idea  ;  (2)  direct  contagion ;  and  (3)  the  presence 
of  the  germ  in  external  media,  especially  in  water,  and  its  trans- 
mission in  that  way.  This  last  is  the  most  generally  accepted 
theory.  Brouardel  in  1887  admitted  that  though  the  disease  could 
be  propagated  by  water,  air,  the  patient's  linen,  or  the  hands  of 
those  looking  after  him,  yet  in  99  out  of  100  cases  it  was  through 
the  medium  of  water.  The  author  then  gives  the  details  of  an 
epidemic  occurring  in  a  home  for  idiots  and  the  weak-minded. 
After  describing  the  insanitary  condition  of  the  river,  M.  Legrain 
draws  attention  to  the  increasing  prevalence  of  gastro-intestinal 

"Geneve.     Taponnier  et  Studer.     1890.     Page  15. 

b  Crnonian  Lectures,  1880. 

c  Correspondem-Blatt  fur  tchweiz.  Aerlze.     No.  75.     1878. 


360  ENTERIC   FEVER. 

affections  in  the  home.  Thus  among  an  average  of  170  treated 
yearly,  there  were  25  such  cases  in  1887,  57  in  1889,  and  84  in 
1890,  the  epidemic  taking  place  from  January  to  May  of  the  last- 
named  year.  Two  conclusions  are  drawn — (1)  that  the  highest  figure 
representing  the  gastro-intestinal  disturbance  and  that  representing 
enteric  fever  corresponded,  and  (2)  that  the  epidemic  was  the  climax 
of  a  preparatory  period  of  gastro-intestinal  disorders.  The  author 
agrees  with  Chantemesse  that  gastric  disturbance  with  fever,  apart 
from  simple  indigestion,  may  be  abortive  enteric  fever. 

Mode  of  Invasion. — A  question  arises  as  to  the  organ  in  which 
the  typhoid  germs  that  have  once  entered  the  body  first  settle,  and 
afterwards  extend  from  this  their  primary  seat  of  invasion,  so  as 
to  bring  about  the  general  disease.  Eberth  lays  stress  upon  a 
case  observed  by  Meyer,a  in  which  death  ensued  on  the  second  day 
of  illness.  In  this  case  there  were  found  at  the  post-mortem 
examination  hyperemia  of  the  lungs,  spleen,  and  kidneys  ;  in  the 
lower  portion  of  the  ileum  marked  swelling  of  the  solitary  follicles 
and  Peyer's  patches,  but  nowhere  any  trace  whatever  of  necrosis 
or  of  loss  of  substance.  None  of  the  mesenteric  glands  were 
swollen.  In  this  recent  case,  microscopical  examination  revealed 
an  exceptionally  large  deposit  of  the  bacilli  of  Eberth  and  Koch  in 
the  cells  of  the  submucosa  and  in  the  intermediate  muscular  layers. 

Eberth  concludes  from  this  case  that  the  bacilli  are  first  localised 
in  the  intestinal  mucous  membrane,  that  thence  they  pass  into  the 
mesenteric  glands,  thence  into  the  blood-stream  and  accumulate 
again  in  the  spleen,  and,  as  Gaffky  would  add,  in  the  other  organs. 
Eberth  further  points  out  that  anatomical  investigations  have  afforded 
no  evidence  of  the  admission  of  typhoid  germs  through  the  lungs.  On 
this  point  Gaffky  does  not  agree,  for  he  considers  it  as  highly  pro- 
bable— or  at  least  the  possibility  cannot  be  contested — that  the  lungs 
may  occasionally  represent  the  seat  of  invasion.  Be  this  as  it  may, 
there  is  no  doubt  that  a  close  correlation  exists  between  enteric  fever 
and  that  variety  of  acute  pneumonia,  or  pneumonic  fever,  to  which 
the  term  "  Pythogenic  Pneumonia  "  is  now  applied. 

a  Der  Typhus-Bacillus  unci  die  intcstinelle  Infection.  Volkmann's  Klinische 
Vortrage.     1883.    No.  220. 


ENTERIC    FEVER.  301 

At  the  time  of  writing  (November,  1891),  there  is  under  my  care 
in  the  Meath  Hospital  a  young  woman  with  characteristic  typhoid 
stools,  and  whose  urine  gives  a  striking  reaction  with  Ehrlich's 
test;  but  whose  illness  began  with  right  apex  pneumonia,  with 
rapid  breathing,  cough,  glutinous  expectoration  (not,  indeed,  deeply 
coloured  when  the  patient  was  first  seen  by  me),  dulness  on  per- 
cussion, and,  finally,  the  most  typical  crepitus  redux. 

Towards  the  end  of  October,  1882,  the  following  remarkable  out- 
break of  disease  came  under  my  notice.  On  the  12th  of  that  month 
a  lad,  aged  thirteen,  was  admitted  into  Cork-street  Fever  Hospital 
from  6  Malpas-street,  Dublin,  suffering  from  acute  pneumonia. 

Malpas-street  is  very  unhealthy — the  houses  are  old  and  dirty, 
ill-drained  and  dilapidated.  The  street  runs  down  to  the  bottom 
of  a  valley,  through  which  a  small  tributary  of  the  Poddle  river 
flows  sluggishly.  The  district  is  a  prolific  hotbed  of  disease.  On 
Oct.  31  the  boy's  father  (John  C),  a  boatman,  aged  thirty-six, 
came  in  with  the  same  disease.  On  the  20th  of  the  same  month 
two  girls,  both  aged  fourteen,  were  admitted  to  the  Meath  Hospital 
in  enteric  fever — one  from  11  Malpas-street  and  the  other  from 
No.  13.  On  Nov.  27  a  girl,  aged  twenty,  was  admitted  to  Cork- 
street  Hospital  in  enteric  fever  from  7  Malpas-street,  next  door  to 
the  house  from  which  the  two  cases  of  pneumonia  had  come  a  few 
weeks  previously.  On  Dec.  12,  John  C,  was  again  admitted  to 
the  Meath  Hospital  from  6  Malpas-street  with  "  renal  dropsy."  It 
was  he  who  suffered  from  pythogenic  (?)  pneumonia  in  the  pre- 
vious October,  as  narrated  above.  Another  coincidence  occurred  in 
March,  1883.  On  the  18th  of  that  month  Winifred  N.,  aged  nine- 
teen, came  into  Cork-street  Hospital  from  6  Malpas-street  in  an 
attack  of  "  f ebricula,"  and  the  following  day  Anthony  L.,  aged 
twenty-seven,  was  admitted  from  the  same  house  with  left  basic 
croupous  pneumonia. 

A  very  similar  instance  of  the  correlation  existing  between 
enteric  fever  and  pneumonia  came  under  my  observation  in  the 
autumn  of  1881.  Four  cases  of  illness  occurred  in  a  Training 
College  in  Dublin  within  a  few  weeks.  Two  of  the  four  patients 
suffered  from  true  enteric  fever ;  a  third,  from  an  attack  of  acute 


362  ENTERIC   FEVER. 

gastro-intestinal  catarrh  or — as  some  may  think — from  an  abortive 
enteric  fever ;  and  a  fourth  from  acute  pneumonia,  reminding  one 
of  Laennec's  "  epidemic  pneumonia,"  which  in  recent  times  has 
received  the  names  of  'v  sewer-gas  "  or  "  pythogenic  "  pneumonia. 
The  drinking-water  was  proved  by  Sir  Charles  Camerona  to  be  the 
source  of  the  sickness  in  all  the  four  cases. 

"  Whether  it  be,"  writes  Gaffky,  "  that  the  spores  of  the  typhoid 
bacilli  are  taken  up  in  drinking  water,  or,  in  rare  cases,  along  with 
articles  of  food  ;  whether  it  be  that  they  are  inspired  with  the  air 
breathed,  remain  attached  to  the  mucous  membrane  of  the  mouth 
and  throat,  and  are  afterwards  swallowed,  in  all  probability  they 
pass  without  damage  through  the  stomach,  sprout  to  form  bacilli  in 
the  alkaline  contents  of  the  intestine,  multiply  there  and  penetrate 
into  the  intestinal  mucous  membrane  at  those  spots  which  are  most 
adapted  for  their  reception— viz.,  the  Peyer's  patches  and  solitary 
follicles.  Afterwards  they  arrive  in  the  mesenteric  glands,  where 
they  form  the  very  numerous  characteristic  masses,  and  are  then 
carried  away  in  the  blood-current  into  the  other  organs.  Becoming 
fixed  here  and  there  in  these,  they  multiply  to  form  those  group.«, 
the  almost  constant  presence  of  which  in  the  spleen,  liver,  and 
kidneys,  has  been  described  in  detail  in  the  earlier  part  of  this  work. 
Obviously  the  infection  will  be  more  certain  to  ensue  the  greater 
the  number  of  spores  taken  into  the  body." 

Virchow b  maintained  that  infection  in  enteric  fever  most  fre- 
quently took  place  by  means  of  drinking  water.  He  wrote  :  "  The 
striking  limitation  of  the  anatomical  changes  to  a  deeply  situated 
portion  of  the  intestine,  the  lower  end  of  the  ileum  and  caecum,  seems 
to  indicate  that  a  local  action  of  the  morbific  matter  takes  place,  as 
these  are  exactly  the  situations  where  the  contents  of  the  intestine  are 
relatively  most  frequently  retarded,  where  therefore  the  longest  con- 
tact with  the  mucous  membrane  occurs.  This  consideration  harmo- 
nises best  with  the  inception  of  the  typhoid  matter  in  drinking  water." 

a  Dull.  Journ.  of  Med.  Science.     February,  1882. 

b  "  Canalisation  oder  Abfuhr.  Eine  hygienische  Studie."  Virchow's  Archiv^ 
Band  45.     Heft  2.     Side  294. 


363 


CHAPTER  XXXVII. 
Clinical  Description  of  Enteric  Fever. 

Stage  of  Incubation  or  Latent  Period— Stage  of  Invasion — Stage  of 
Glandular  Enlargement  —  Ulceration  and  Sloughing —  Amphibolic 
Stage — Stage  of  Lysis — Convalescence — Duration  of  the  Fever. 

As  in  the  case  of  Typhus,  we  may  most  conveniently  consider  the 
clinical  history  of  Enteric  Fever  as  the  disease  passes  through  the 
different  periods  or  phases  of  its  development — the  stages,  in  fact, 
of  incubation,  invasion,  glandular  enlargement,  ulceration  or  slough- 
ing of  the  intestinal  glands  and  lysis, and  convalescence   (Murchison.) 

I.  Stage  of  Incubation. — From  elaborate  researches,  Murchison 
was  led  to  conclude  that — 1.  The  period  of  Incubation  of  enteric 
fever  is  most  commonly  about  two  weeks ;  2.  Instances  of  a  longer 
duration  are  more  common  than  in  typhus  or  relapsing  fever ;  3. 
It  is  often  less  than  two  weeks,  and  may  not  exceed,  one  or  two 
days. 

Liebermeister  admits  that  the  period  of  incubation  is  difficult  to 
be  determined,  because  "  it  is  hard  to  fix  the  exact  date  of  the 
infection,  and  often  hard  to  fix  that  of  the  commencement  of  the 
disease,"  He  considers  that,  according  to  our  present  (1875) 
experience,  the  average  period  of  incubation  is  three  weeks.  In  a 
paper,  "  Ueber  die  Incubationzeit  des  Abdominaltyphus,"  published 
in  1875,  Professor  Quincke,8  of  Berne,  gave  some  cases — due  to 
drinking  contaminated  water— in  which  the  duration  of  incu- 
bation was  very  accurately  ascertained.  In  these  eases  the 
shortest  period  was  eight  days,  the  longest  certain  period  between 
sixteen  and  eighteen  days.  In  the  Marylebone  milk  epidemic  of 
1873,  a  child  was  taken  ill  five  days  after  drinking  the  infected 
milk  (Cayley).     Hilton  Fagge  is  responsible  for  the  statement  that 

a  Correspondenz-Blatt  Jiir  schweizer  Aerzte.     1875.     No.  8. 


364  ENTERIC   EEVER. 

it  has  been  conjectured  the  incubation  is  shorter  when  the  poison 
is  inhaled  with  the  breath,  longer  when  it  is  swallowed  in  drinking 
water. 

During  this  latent  period,  the  patient  may  feel  quite  well,  or, 
on  the  other  hand,  he  may  complain  of  being  "out  of  sorts  ;  "  there 
may  be  languor,  a  tendency  to  diarrhoea,  and  vague  feelings  of 
discomfort  and  chilliness,  with  headache  and  loss  of  appetite. 

II.  Stage  of  Invasion. — This  lasts  from  the  first  marked  feeling 
of  illness  until  decided  febrile  symptoms  have  developed.  It  is  a 
badly  defined  period,  for  the  advent  of  enteric  fever  is  essentially 
gradual  and  insidious  in  most  cases.  It  lasts,  according  to 
Murchison,  for  one  or  more  days. 

Of  late  years  the  classical  insidious  onset  of  enteric  fever  has 
in  many  instances  given  place  to  a  more  abrupt  and  vehement 
advance,  characterised  by  decided  rigors,  violent  headache,  and 
rapid  rise  of  temperature.  This,  at  least,  has  been  our  experience 
in  Dublin  during  and  since  the  epidemic  of  1889.  In  a  word,  the 
whole  course  of  the  disease  has  become  more  typhus-like  than 
formerly. 

The  earliest  symptoms  are,  headache  and  pains  in  the  limbs,  with 
irregular  chills,  giddiness,  and  languor.  Sometimes  nausea  and 
vomiting  are  prominent  symptoms,  and  still  more  frequently  there 
is  urgent  diarrhoea,  particularly  if  the  patient  has  taken  a  saline 
aperient  while  under  the  impression  that  he  is  suffering  from  a 
mere  bilious  attack. 

III.  Stage  of  Glandular  Enlargement. — This  overlaps  the  inva^ 
sion,  and  extends  to  the  twelfth  or  fourteenth  day.  The  pulse 
now  increases  in  frequency,  temperature  rises,  especially  in  the 
afternoon  or  evening,  the  fever  being  of  a  remittent  type,  the  skin 
is  hot,  the  tongue  is  furred  and  red  at  the  edges,  and  epistaxis  is  apt 
to  occur.  The  nights  are  restless  and  disturbed,  and  the  patient 
feels  weak,  but  not  to  anything  like  the  same  extent  as  in  typhus. 
Indeed  it  is  quite  usual  for  the  sufferer  from  enteric  fever  to  pursue 
his  ordinary  avocations  during  the  whole  of  the  first  week  of  his 
illness,  or  even  longer. 

So  far  there  is  nothing  absolutely  pathognomonic  of  enteric  fever, 


ENTERIC    FEVER.  305 

but  Murchison  points  out  that  the  concurrence  of  diarrhoea  or  gastric 
disturbance,  with  an  evening  temperature  of  103°  or  104°  F.  and 
prostration,  in  a  young  person,  ought  always  to  make  the  practi- 
tioner suspect  that  this  is  the  disease  which  he  has  to  combat. 

In  very  rare  instances  enteric  fever  sets  in  with  sudden  maniacal 
delirium  (Hilton  Fagge).  On  the  other  hand,  a  person  may  ail  for 
one,  two,  or  three  weeks,  after  which  a  definite  attack  of  this  fever 
may  begin  and  run  its  usual  course. 

At  the  close  of  the  first  week  and  during  the  early  days  of  the 
second,  the  symptoms  are  more  or  less  headache,  prostration,  loss 
of  appetite,  diarrhoea  with  liquid  motions  of  an  ochrey-yellow 
colour,  a  frequent  soft  pulse  liable  to  great  variations  in  rate  and 
strength,  fever  of  a  variable  remittent  type.  There  is  a  warm,  dry 
skin,  with  occasional  clammy  sweating.  The  pupils  are  dilated, 
and  the  conjunctivae  are  clear,  the  nose  bleeds  from  time  to  time, 
there  is  a  clear  complexion  with  a  hectic  flush  upon  the  cheek, 
so  that  the  patient  is  like  one  in  pulmonary  consumption. 

The  tongue  is  at  first  covered  with  a  creamy  fur,  through  it  the 
enlarged  papillae  begin  to  show,  and  a  triangular  red  space  appears 
at  the  tip.  The  edges  also  are  red.  The  epithelium  is  subsequently 
shed,  and  the  surface  of  the  whole  organ  in  severe  cases  becomes 
red,  glazed,  dry,  and  transversely  fissured  and  sore.  Occasionally 
the  tongue  becomes  cracked,  dry,  and  brownish.  In  most  cases, 
but  not  invariably,  the  area  of  splenic  dulness  is  increased.  Tym- 
panites, or  meteorism,  is  commonly  observed,  sometimes  to  an 
extreme  degree.  There  is  tenderness  on  pressure  over  the  abdomen, 
with  gurgling  (gargovillement)  in  the  iliac  fossae.  Intestinal  haemo- 
rrhage may  occur.  Occasionally  constipation  prevails  and  may 
even  be  obstinate. 

The  Rose-Rash. — Between  the  seventh  and  twelfth  days  an 
eruption  of  isolated,  elevated,  rose-coloured  spots  first  appears, 
chiefly  over  the  abdomen  and  back.  The  soft  papules,  of  which 
this  almost  pathognomonic  rash  consists,  are  deleble  on  pressure, 
vanishing  to  reappear  when  pressure  is  removed.  They  come  out 
in  successive  crops  for  ten  days  or  a  fortnight,  or  longer,  each  crop 
lasting  for  two,  three,  or  more  days.     There  may  be  only  three  or 


366  ENTERIC   FEVER. 

four  rose-spots,  but  on  the  other  hand  they  may  be  counted  by 
hundreds. 

This  stage  of  the  fever  derives  its  name  from  the  enlargement  of 
the  intestinal  and  mesenteric  glands  which  is  proceeding  apace 
during  the  first  fortnight  of  the  disease. 

IV.  Stage  of  Ulceration  and  Sloughing. — This  stage  extends 
from  about  the  twelfth  or  fourteenth  day  to  some  time  between  the 
twenty-first  and  twenty-eighth  day  (Murchison). 

In  mild  cases  cerebral  symptoms  may  be  wanting,  but  in  the 
severer  forms  of  enteric  fever  headache  gives  place  in  the  third 
week  to  somnolence,  increasing  delirium,  particularly  at  night,  and 
progressive  nervous  and  muscular  prostration.  Inordinate  tremor 
is  regarded  by  Sir  William  Jenner  as  indicative  of  the  pre- 
sence of  deep  ulceration  of  the  intestine,  such  as  is  likely  to  lead 
to  perforation  or  haemorrhage,  and  Murchison  held  the  same  opinion. 
In  these  serious  cases  also  sordes  collect  on  the  teeth,  diarrhoea 
persists,  the  tongue  is  dry,  glazed,  red,  and  fissured,  and  bed-sores 
are  apt  to  form  over  the  sacrum  and  near  the  great  trochanters. 
The  patient  daily  loses  strength  and  wastes  rapidly,  and  at  last  the 
"  typhoid  "  or  "  ataxic  state,"  of  which  I  have  so  often  made  men- 
tion, may  be  developed,  the  patient  either  dying  of  coma  or  slowly 
improving  towards  the  close  of  the  third  or  in  the  fourth  week. 

In  many  instances,  the  typhoid  stage  is  never  reached.  Yet  the 
patient  is  not  free  from  danger,  for,  apart  from  pulmonary  or  other 
complications,  he  may  succumb  in  the  third  or  fourth  week  to  one 
or  other  of  the  perilous  results  of  the  intestinal  lesions — exhausting 
diarrhoea,  haemorrhage,  or — most  perilous  of  all — perforation  of  the 
intestine,  and  peritonitis — with  or  without  perforation — local  or 
general. 

The  duration  of  this  stage  is  uncertain,  and  for  a  time  there 
may  be  a  period  of  uncertainty,  or  of  changing  fortunes  (Murchi- 
son), to  which  Wunderlicha  has  given  the  name  of  the  amphibolic  b 
stage.  This  doubtful  period  usually  follows  the  acme,  or  fasti- 
gium,  of  the  fever,  and  in  it  the  range  of  temperature  is  more  or 

"  Medical  Thermometry.     New  Syd.  Soc.     1871.     Pa»e  315. 

b  Gk.  a/x<pi0o\os,  attacked  on  both  or  all  sides  j  hence,  doubtful,  ambiguous. 


ENTERIC    FEVER.  367 

less  irregular.  After  remissions,  or  even  a  partial  collapse,  recru- 
descences of  the  fever,  lasting  for  several  days,  may  occur.  These 
"flarings"  of  the  expiring  fever  must  be  distinguished  from  true 
relapses  in  convalescence. 

V.  Stage  of  Lysis. — As  it  usually  begins,  so  enteric  fever  ends — 
gradually.  Resolution  takes  place  by  lysis,  not  by  crisis.  This  is 
the  rule,  but  there  are  exceptions  to  it.  For  example,  Dr.  Hilton 
Fagge  cites  the  case  of  a  medical  friend,  whose  temperature  (which 
had  been  ranging  between  101°  and  103°  with  great  regularity) 
was  found  about  the  twentieth  evening  to  be  only  101*1°;  next 
morning  it  was  100°,  in  the  evening  99-3°  ;  on  the  twenty-second 
morning  it  was  98,3°,  and  for  several  days  afterwards  it  remained 
slightly  below  normal.  A  very  similar  case  has  lately  passed 
through  the  hands  of  Dr.  H.  T.  Bewley,  of  the  Adelaide  Hospital, 
Dublin.  Through  his  kindness  I  have  been  enabled  to  reproduce 
the  temperature  chart  of  his  patient's  case  in  Plate  VIII.  (Fig.  9). 
In  most  cases,  however,  the  fever  subsides  day  by  day,  and  the 
morning  temperatures  may  not  exceed  99°  or  S8°  or  97°,  while 
the  evening  readings  still  reach  104°  or  103°  or  102°.  The  tem- 
perature range,  therefore,  is  of  an  intermittent  or  remittent  type. 

These  "spikings"  of  the  temperature  daily  tend  to  become  less 
and  less  marked.  Simultaneously,  the  tongue  becomes  moist — its 
epithelial  coat  being  replaced — the  head  symptoms  abate,  and  fresh 
rose-spots  fail  to  appear. 

VI.  Convalescence,  according  to  Murchison,  can  be  said  to  be 
fairly  established  only  when  the  temperature  is  normal  on  two  successive 
evenings.  Independently  of  its  liability  to  interruption  by  compli- 
cation1, relapses,  or  sequelae,  this  stage  is  slow  and  halting.  The 
pulse  remains  quick,  and  appetite,  health,  and  strength  are  regained 
only  by  degrees.  I  have  repeatedly  met  with  instances  in  practice 
where  six  months,  or  even  a  year,  elapsed  before  the  wonted  health 
and  strength  returned. 

Duration  of  Enteric  Fever. — In  ordinary  cases  this  is  from 
three  to  four  weeks.  Of  200  cases  which  recovered,  Murchison 
ascertained  the  mean  duration  to  be  24-3  days;  of  112  cases  which 
proved  fatal,  the  mean  duration  was  27*67  days.     Of  215  cases 


31)8  ENTERIC    FEVER. 

noted  by  C.  E.  Hoffmann,a  the  mean  duration  was  28*9  days.  In 
children,  especially,  the  fever  may  terminate  several  days  before 
the  end  of  the  third  week  (Hilton  Fagge).  On  the  other  hand, 
death  may  supervene  at  an  early  date,  rarely  however,  before  the 
fourteenth  day.  Both  Trousseau b  and  Hoffmann,0  indeed,  report 
each  a  case  fatal  in  less  than  four  days,  and  Murchison d  gives 
details  of  one  fatal  in  47  hours.  Trousseau's  case  of  short  duration 
is  particularly  interesting,  because  he  was  able  to  fix  with  precision 
the  date  at  which  the  attack  began,  and  after  death  on  the  fifth 
day,  the  intestinal  lesions  were  found  present  in  a  marked  degree — 
"l'autopsie  cadaverique  permit  de  constater  l'existence  d'une  des 
eruptions  dothienenteriques  les  plus  confluentes  que  nous  ayons 
jamais  vues,  et,  chose  remarquable,  nous  n'etions  qu'au  cinquieme 
jour  de  la  maladie." 

a  U»tersuchungen  iiber  die  path.  anat.  Veranderwigen  der  Organe  beim  Abdomi- 
naltypkus.     Leipzig.     1869. 

b  Clinique  med.  de  V Hdtel  Dieu  de  Paris.     1865.     Vol.  I.,  page  244. 

c  hoc  cit.,  p.  38. 

d  Murchison.     1884.     3rd  Edition.     Page  551. 


369 


CHAPTER  XXXVIII. 

Analysis  of  the  Symptoms  of  Enteiuc  Fever. 

The  Physiognomy  of  Enteric  Fever.— The  Surface  :  lenticular  rose-spots, 
taches  bleudtres,   purpura  spots,   vibices,  sudamina,  accidental  or  adventitious 

rashes. — Desquamation. — The  Circulation. — The  Respiratory  System. The 

Digestive  System  :  nausea,  vomiting,  meteorism  or  tympanites,  gargnuillement, 
constipation,  diarrhoea,  intestinal  haemorrhage. — Spleen. — The  Urinary 
System. — The  Nervous  System  :  Liebermeister's  four  grades  of  nervous  dis- 
turbance.— Angel  Money's  observations  on  muscular  irritability. — Organs  of 
Special  Sense  :  the  eye,  ear,  nose,  cutaneous  sensibility. — Emaciation. 

Following  Murchison's  systematic  plan,  let  us  now  consider  the 
different  symptoms  in  more  detail. 

I.  The  Physiognomy. — The  patient  in  enteric  fever  wears  an 
expression  of  languor,  ennui,  and  even  sadness.  The  heavy  stupid 
expression  of  typhus  (Facies  typhosa)  is  absent  except  in  those 
severe  cases  where  the  disease  assumes  the  typhoid  or  ataxic  state. 
There  is  commonly  a  pink  blush  on  one  or  both  cheeks,  like  the 
flush  of  hectic  fever  in  a  consumptive  patient. 

II.  The  Surface. — The  skin  is  at  first  hot  and  dry,  becoming 
moist  in  the  evenings  ;  afterwards  a  tendency  to  perspiration  be- 
comes more  decided.  After  the  seventh  day  small,  circular,  pink 
or  rose-coloured  spots  appear,  in  greatest  number  on  the  lower 
part  of  the  abdomen  and  the  back.  The  total  number  may  not 
exceed  ten,  twenty,  or  thirty ;  but,  on  the  other  hand,  there  may 
be  several  hundred.  These  spots  are  elevated  and  resemble  papules 
of  smallpox  in  their  first  stage,  but  unlike  them  they  are  never 
hard  or  "  shotty."  They  can  be  felt  as  rounded — not  conical — 
elevations  in  the  skin.  It  is  necessary  to  look  for  them  the  moment 
the  surface  of  the  body  is  stripped,  for  exposure  to  the  cold  air  at 
once  causes  the  development  of  cutis  anserina.  As  a  result  of  this, 
the  arterioles  of  the  skin  are  compressed  and  themselves  contract. 
In  this  way  the  blood  supply  to  the  rose  spots  is  cut  off,  so  that 
they  become  pale  or  entirely  disappear  for  a  time.  They  disappear 
on  pressure  to  reappear  once  pressure  is  removed.  Their  diameter  is 
from  half  a  line  to  two  lines.  In  profile,  they  are  like  little  lenses 
set  in  the  skin — hence  Louis'  term  adopted  by  Trousseau — taches 

2  ij 


370 


ENTERIC   FEVER. 


rosees  lenticulaires,  that  is,  lens-like,  or  lenticular,  rose-spots.  The 
rose-spots  come  out  in  successive  crops,  each  set  lasting  three  or 
four  days ;  and  this  goes  on  for  seven,  fourteen,  or  even  twenty-one 
days.  There  is  no  relation  between  the  number  of  the  spots  and 
the  severity  of  the  attack.  They  disappear  after  death,  and  never 
become  petechial  during  life.  From  the  statistics  of  the  London 
Fever  Hospital  the  rash  of  enteric  fever  would  seem  to  be  present 
in  77  per  cent,  of  the  cases.  Liebermeister  thinks  that  the  rash  is 
seldom  absent  at  some  stage  of  the  fever,  but  there  can  be  no 
doubt  that  it  is  often  wanting,  more  particularly  in  children. 

Murchison  draws  the  following  contrast  between  the  rose-spots 
of  enteric  fever  and  the  maculae  of  tvphus: — 

Enteric  Fever.  Tvphus. 

1.  Pink  or  rose-coloured  throughout.        1.  May  be  dirty  pink  or  red  at  first, 


2.  Undergo   no    change,    until   they 

fade  or  disappear.     Never  con- 
verted into  petechias. 

3.  Circular — half  a  line  to  two  lines 

in  diameter. 

4.  Isolated  and  few  in  number. 

5.  No  subcutaneous  mottling. 

6.  Elevated  above  the  skin. 

7.  Disappear  on  pressure  as  long  as 

they  last. 

8.  Rarely  appear  before  the  7th  day. 

9.  Appear  in  successive  crops. 

10.  Each  spot  lasts  only  three  or  four 

days. 

11.  Never  present  on  the  dead  body. 

12.  A  large  number  does  not  indicate 

danger. 


but  soon  become  reddish-brown. 

2.  Become  gradually  darker,  and  are 

often  converted  into  petechias. 

3.  Of  irregular  form. 

4.  Numerous,  and  adhere  in  patches. 

5.  Mottling  in  addition  to  spots. 

6.  Not    elevated,    except  at    lirst 

appearance. 

7.  Do  not   disappear   on  pressure, 

except  at  first. 

8.  Appear  on  4th  or  5th  day. 

9.  Never  in  successive  crops. 

10.  Many  of  the  spots  may  last  to  the 

end  of  the  fever. 

11.  Often  persist  after  death. 

12.  Direct  ratio  between  the  number 

and  darkness  of  the  spots  and  the 


severity  of  the  case. 
Besides  these  pathognomonic  rose-spots,  spots  of  a  delicate  blue- 
tint  of  indefinite  size  and  shape  are  sometimes  observed  on  the  fair 
skin  over  the  abdomen  and  back  of  the  typhoid  patient.  These 
are  the  maculae  caeruleae  of  the  writers,  the  taches  bleuatres  of 
the  French.  There  is  nothing  pathognomonic  in  these  markings — 
first,  because  they  are  found  in  other  diseases,  such  as  pneumonia, 


ENTERIC   FEVER.  371 

simple  fever,  and  non-maculated  typhus;  secondly,  because  they 
seem  to  arise  from  an  independent  cause — the  irritation  of  pediculi 
(see  page  236). 

Other  epiphenomena  of  the  disease  connected  with  the  skin 
are : — purpura  spots,  vibices,  and  sudamina  or  sweat-vesicles. 
The  last-named  are  thus  described  by  Trousseau,  in  his  Clinique 
Medicate  de  VHotel  Dieu: — "La  miliaire  pellucide,  improprement 
appebie  sudamina,  qui  apparait  ordinairement  du  onzieme  au  vingt- 
ieme  jour,  quelquefois  plus  tard,  est  constitute  par  de  petites  bulles, 
arrondies  ou  oblongues,  ressemblant  alors  a  des  larmes,  remplies 
d'un  liquide  transparent." 

Occasionally  the  skin  is  affected  by  the  co-existence  with  enteric 
fever  of  other  specific  diseases  showing  characteristic  symptoms, 
such  as  scarlatina,  measles,  smallpox,  and  above  all  typhus. 

In  addition  to  all  the  foregoing,  I  drew  attention,  in  a  paper a 
read  before  the  Royal  Academy  of  Medicine  in  Ireland  on  Novem- 
ber 16,  1888,  to  certain  other  accidental  or  adventitious  appear- 
ances of  the  skin,  which  are  of  a  somewhat  rare  occurrence, 
but,  from  a  diagnostic  point  of  view,  of  considerable  importance. 
These  are — (1)  Simple  HyperEemia ;  (2)  Miliary  Eruptions; 
(3)  Erythematous  Hashes;  (4)  Urticaria. 

In  the  four  cases  detailed  in  that  paper,  there  was  no  evidence 
to  connect  the  skin  rashes  with  the  administration  of  any  drugs. 

It  is  necessary  to  make  this  statement,  remembering,  with  Dr. 
Radcliffe  Crocker,6  that  "  a  precisely  similar  rash  occurs  after 
certain  drugs,  especially  copaiba,  quinine,  belladonna,  salicylic  acid, 
and  others.  In  these  cases  the  rash  is  probably  due  to  irritation  of 
the  alimentary  canal  acting  reflexly  on  the  vaso-motor  centre." 

The  conclusions  I  arrived  at  were  as  follow : — 

1.  Not  infrequently,  in  the  course  of  enteric  fever,  an  adventitious 
eruption  occurs,  either  miliary,  urticarious,  or  erythematous. 

2.  When  this  happens,  a  wrong  diagnosis  of  typhus,  or  measles, 
or  scarlatina  may  be  made,  if  account  is  not  taken  of  the  absence 
of  the  other  objective  and  subjective  symptoms  of  these  diseases. 

a  Accidental  Rashes  in  Typhoid  Fever.  Trans.  Royal  Acad,  of  Med.  in  Ire- 
land.    1889.     Vol.  VII.,  page  10. 

b  Diseases  of  the  Skin.     London  :  H.  K.  Lewis.     1888.     Page  58. 


372  ENTERIC  FEVER. 

3.  The  erythematous  rash  is  the  most  puzzling  of  all ;  but  the 
prodromata  of  scarlet  fever  are  absent,  nor  is  the  typical  course  of 
that  disease  observed. 

4.  This  erythema  scarlatiniforme  is  most  likely  to  show  itself  at 
the  end  of  the  first,  or  in  the  third  week  of  fever. 

5.  In  the  former  case,  it  probably  depends  on  a  reactive  inhibi- 
tion of  the  vaso-motor  system  of  nerves ;  in  the  latter,  on  septi- 
caemia, or  secondary  blood-poisoning ;  or  both  these  causes  may  be 
present  together. 

6.  The  cases  in  which  this  rash  appears  are  often  severe ;  but 
its  development  is  important  rather  from  a  diagnostic  than  from  a 
prognostic  point  of  view. 

7.  Hence,  no  special  line  of  treatment  is  required  beyond  that 
already  employed  for  the  safe  conduct  of  the  patient  through  the 
fever. 

The  erythematous  rash  here  alluded  to  is,  without  doubt,  the  Ery- 
thema punctatum  of  Dr.  M'Call  Anderson,a  the  Erythema  scarlatini- 
forme of  Hardy,  the  Roseole  scarlatiniforme  of  Basin,  the  Symptomatic 
Erythema  of  Dr.  James  Nevins  Hyde,b  the  Erythema  scarlatiniforme 
of  Dr.  H.  Radcliffe  Crocker,0  the  Diffuse  Erythema  of  Liebermeister,d 
the  Scarlet  Rash  of  Charles  Murchison.e 

On  April  13,  1883,  Dr.  Thomas  Whipham  read  a  paper  before 
the  Clinical  Society  of  London,  entitled  "  Two  Cases  of  Enteric 
Fever  accompanied  by  an  Erythematous  Eruption  resembling  that 
of  Scarlatina."  f 

The  most  important  point  about  Dr.  Whipham's  two  cases  is  that 
they  both  proved  fatal,  and  that  an  opportunity  was  afforded  in 
each  instance  of  verifying  the  diagnosis  of  enteric  fever  by  a  post- 
mortem examination. 

According  to  an  abstract  from  the  pen  of  Dr.  Robert  Saundby 

a  A  Treati?e  on  Diseases  of  the  SJcin.  London  :  Charles  Griffin  &  Co.  1887. 
Page  89. 

b  A  Practical  Treatise  on  Diseases  of  the  Skin.  Second  Edition.  London  : 
J.  &  A.  Churchill.     1888.     Page  154. 

c  Loc.  cit.     Page  58. 

d  Von  Ziemssen's  Cyclopaedia  of  the  Pract.  of  Med.     1875.     Vol.  I.,  p.  183. 

•  The  Continued  Fevers  of  Great  Britain.     Third  Edition.     1884.     Page  516. 

f  Transactions  of  the  Clinical  Society  of  London.    Vol.  XVI.,  page  15& 


ENTERIC    FEVER.  373 

in  the  London  Medical  Record  of  December  15,  1878,  MM.  Ray- 
mond and  Nelaton  reported  in  Le  Progres  Medical  of  October  19  of 
the  same  year,  the  histories  of  two  cases  of  typhoid  fever  in  the 
wards  of  M.  Moutard-Martin,  at  the  Hopital  Beaujon,  which  were 
accompanied  by  a  very  singular  eruption,  both  in  its  aspect,  its 
course,  and  the  time  of  its  appearance.  MM.  Raymond  and  NeMa- 
ton  remark  that  analogous  rashes  have  been  recorded,  in  particular 
by  Griesinger,  who  says : — {'  In  rare  cases  we  observe,  at  the  same 
time  as  the  roseola  [i.e.,  the  rose-spot  eruption],  a  rash  like  urti- 
caria." To  their  two  cases  MM.  Raymond  and  Nelaton  add  a 
third  noticed  by  M.  Moutard-Martin,  in  which  a  rash  resembling 
that  caused  sometimes  by  copaiba,  and  which  he  called  first 
u  febrile  urticaria,"  but  afterwards  "  papular  erythema,"  super- 
vened on  the  sixth  day  of  typhoid  fever.  The  rash  gradually  lost 
its  bright  colour,  and  slowly  disappeared.  The  hands  and  feet 
desquamated  in  large  patches ;  the  rest  of  the  body  showed  only 
branny  desquamation.  As  to  the  cases  observed  by  MM.  Ray- 
mond and  Nelaton,  they  believe  that  they  were  not  scarlatina,  for 
the  following  reasons : — 1 .  The  form  of  the  eruption,  and  its  pre- 
dominance in  parts  unusual  in  that  disease.  2.  The  absence  of 
prodromata,  and  of  the  concomitant  scarlatinal  symptoms,  angina, 
state  of  tongue,  &c.  3.  The  course  followed  by  the  desquamation. 
On  the  hands  there  were  no  large  flakes.  One  of  the  patients 
showed  the  rash  on  the  fifteenth  day  of  his  fever;  the  other 
showed  it  on  the  eleventh  or  twelfth  day.  Both  cases  were  very 
severe,  and  were  of  an  ataxo-adynamic  type. 

In  the  Proceedings  of  the  "Soci^te"  Medicale  des  Hopitaux  de 
Paris"  for  1873,  M.  Siredey  reports  a  case  in  which  "towards 
the  fifteenth  day  of  a  typhoid  fever  a  scarlatiniform  erythema 
appeared,  which,  commencing  in  the  right  cheek,  spread  rapidly 
over  the  face  and  neck,  and  by  the  following  day  occupied  the 
whole  surface  of  the  body.  Almost  immediately,  in  the  groins, 
the  axilla,  and  on  the  back,  the  epidermis  was  raised  by  a  serous 
exudation."  M.  Guyot,  consulted  by  M.  Siredey,  agreed  with  him 
in  rejecting  the  notion  of  its  being  scarlatina;  nevertheless,  de- 
squamation occurred  in  large  flakes. 


374  ENTERIC    FEVER. 

It  is  not  easy  to  arrive  at  a  satisfactory  conclusion  as  to  the 
aetiology  of  this  accidental  erythema  in  enteric  fever.  Bearing  in 
mind  that  it  commonly  occurs  early  in  the  disease — when  a  deter- 
mination of  blood  to  the  skin  may  be  presumed  to  have  followed  the 
initial  rigors  of  the  fever — we  may,  with  some  show  of  reason,  attri- 
bute the  development  of  the  exanthem  to  an  inhibition  of  the  vaso- 
motor centre — the  correlative  of  the  stimulation  of  that  centre  by 
which  the  precedent  rigors  are  explained — causing  relaxation  and 
overfilling  of  the  arterioles  of  the  skin,  the  impure  blood  further 
producing  a  passing  dermatitis  in  the  form  of  an  erythema. 

When  the  rash  happens  in  the  second  or  third  week,  we  should 
remember  that  we  are  approaching  the  sweating  stage  of  typhoid 
fever,  and  that  there  is  again  a  determination  of  impure  blood  to 
the  skin.  Or  we  .may  regard  this  later  appearance  of  the  rash  as 
of  septicsemic  origin,  agreeing  in  time  with  the  period  of  "spiking 
temperature,"  which  is  itself  so  suggestive  of  a  septicemic  tendency. 
As  Dr.  Radcliffe  Crocker  says  :  "  It  [erythema  scarlatiniforme] 
is  seen  occasionally  in  septicemic  conditions,  as  after  surgical 
operations,  but  not  so  frequently  since  antiseptic  precautions  have 
been  generally  adopted."  And  this  may  throw  some  light  on  M. 
Trelat's  observations  on  "  Scarlatina  following  Surgical  Opera- 
tions," which  appeared  in  Le  Progres  Medical,  September  14, 
1878,a  as  well  as  on  the  supposed  origin  of  scarlatina  from  the 
decomposition  of  slaughter-house  refuse,  which  was  suggested  many 
years  ago  by  Dr.  Alfred  Carpenter,1*  of  Croydon. 

In  the  British  Medical  Journal  for  December  7,  1878,  there  is  a 
very  interesting  note  on  "  Septicsemic  Eruptions."  In  1868,  M. 
Verneuil  proved  the  existence  of  several  different  cutaneous  erup- 
tions as  taking  place  during  purulent  infection.  About  the  same 
time,  Dr.  Braidwood  was  giving  special  attention  to  the  study  of 
one  of  those  peculiar  forms  of  pyemic  eruptions  which  bear  a  very 
close  resemblance  to  the  erythema  observed  in  scarlatina.  M. 
Gueniot  tried  to  prove,  in  accordance  with  the  well-known  fact 

a  See  Lond.  Med.  Record,  Oct.  15,  1878.     Page  417.     [See  page  157]. 
*  The  Lancet,  January  28,  1871,  page  110  ;  and  Manual  of  Public  Health  for 
Ireland,  1875,  page  169. 


ENTERIC    FEVER.  375 

that  women  who  have  been  recently  confined  are  often  subject  to 
cutaneous  eruptions,  that  scarlatiniform  erytliemata  had  been 
observed,  the  so-called  puerperal  scarlatinoide.  In  addition  to  the 
above-mentioned  two  classes  of  eruptions,  M.  Claudien  Aulnasadds 
a  third,  which  has  also  been  observed  in  the  course  of  purulent 
internal  diseases.  Here  we  have  sufficient  evidence  of  the  septi- 
csemic  or  pyaemic  origin  of  erythema  scarlatiniforme,  whether  in 
enteric  fever  or  in  other  zymotic  diseases  or  blood-poisonings. 

Of  all  these  adventitious  appearances  connected  with  the  skin  in 
enteric  fever,  the  erythematous  rashes  are  the  most  important, 
because  they  may  so  closely  simulate  scarlatina.  The  miliary 
eruption,  if  coupled  with  the  rheumatoid  pains  which  are  not 
infrequently  present  in  typhoid,  might  cause  a  wrong  diagnosis 
of  rheumatic  fever  to  be  made ;  while  nettle-rash  {Germ.  Nessel- 
sucht),  if  associated  with  catarrh,  might  be  taken  for  measles. 
But,  serious  as  we  should  consider  these  errors  of  diagnosis  to  be, 
a  much  more  disastrous  mistake  would  be  the  confounding  of  ery- 
thema with  scarlatina,  or,  conversely,  the  overlooking  of  scarlatina 
in  the  belief  that  the  rash  was  simply  erythema. 

Desquamation  occurs  in  fine  branny  scales.  The  skin  feels 
rough  and,  perhaps,  dry,  while  the  process  is  taking  place.  The 
hair  often  falls  out,  and  atrophic  markings  may  appear  on  the  nails. 

III.  The  Circulation. — The  pulse  varies  much.  At  first  it  does 
not  exceed  90  or  100  beats  in  a  minute  ;  sometimes  its  rate  is  below 
the  normal  standard  (that  is,  72  in  an  adult  male,  84  in  an  adult 
female).  The  prognosis  is  bad  if  the  pulse-rate  in  an  adult  persistently 
exceeds  120.  Another  unfavourable  sign  is  failure  in  volume 
when  the  patient's  arm  is  elevated.  The  pulse  is  often  dicrotic  a 
in  enteric  fever  (Germ,  doppelschlagiger  Puis  ;  Fr.  Pouls  dicrote,  p. 
rebondissant) — that  is,  the  pulse  yields  a  sphygmographic  tracing,  or 
conveys  to  the  fingers  a  sensation  of  a  double  beat  for  each  systole 
of  the  left  ventricle.  Sometimes — as  in  a  case  under  my  care  at 
the  time  of  writing — dicrotism  is  visible  to  the  eye  in  the  radial,  or 
even  the  ulnar,  artery.  Such  a  dicrotic  pulse  indicates  relaxation 
of  the  arterial  walls  and  low  blood-tension  in  the  arteries.     Eepro- 

a  Gk.  S'lKporos,  double-beating     From  Sty,  twice,  Kporew,  to  strike. 


376  ENTEEIC   FEVER. 

duction  of  sphygmograms  of  dicrotism  will  be  found  in  Mnrchison's 
work  (Third  Edition,  page  140,  third  tracing,  Fig.  6),  but  especi- 
ally in  Liebermeister's  monograph  on  "  Typhoid  Fever "  in  von 
Ziemssen's  "  Cyclopaedia  of  the  Practice  of  Medicine."  a  No  sudden 
fall  in  the  pulse-rate  occurs  towards  convalescence  (as  in  typhus), 
nor  is  the  heart  weakened  to  the  same  extent,  or  so  frequently,  in 
enteric  fever  as  in  typhus.  In  this  connection  the  younger  age  of 
the  average  typhoid  patient  is  to  be  remembered. 

IV.  The  Respiratory  System. — Little  need  be  said  on  this  point. 
The  rate  of  breathing  as  a  rule  varies  with  that  of  the  pulse,  unless 
the  latter  is  very  slow.  There  may  be  "  nervous  respiration,"  and 
the  breath  is  offensive  in  the  "  typhoid  "  or  "  ataxic  stage."  The 
occurrence  of  true  pneumonia  as  a  not  infrequent  complication  will 
be  alluded  to  further  on. 

V.  The  Digestive  System. — The  condition  of  the  tongue  has 
been  already  sufficiently  described  (see  page  365).  Nausea  and 
Vomiting  are  common  symptoms — hence  the  name  "  Bilious  Fever  " 
which  is  sometimes  used.  Vomiting  at  the  outset  of  the  attack  is 
not  of  evil  import,  but  later  on — in  the  third  or  fourth  week — it  is 
one  of  the  earliest  symptoms  of  peritonitis.  At  the  same  time,  it 
is  right  to  mention  that  I  have  repeatedly  known  obstinate  vomiting 
at  all  stages  of  enteric  fever  to  depend  on  overfeeding. 

Meteorism,  or  tympanites,  is  very  often  present  and  in  excess, 
principally  over  the  colon.  It  is  usually  associated  with  pain, 
tenderness  on  pressure,  and  diarrhoea. 

Gargouillement,  or  a  sensation  of  gurgling,  in  the  ileo-caecal 
region,  is  often  elicited  on  gentle  pressure.  It  is  supposed  to  mean 
regurgitation  through  the  ileo-caecal  valve,  but  to  my  mind  it  is 
a  sign  of  little  or  no  importance,  and  an  unskilful  search  for  it  may 
seriously  injure  the  patient. 

The  bowels  are  sometimes  even  obstinately  confined  in  enteric 
fever,  although  more  or  less  diarrhoea  is  the  rule.  Constipation  is 
not  a  favourable  indication.  In  1854,  Dr.  Wilksb  found  in  the 
case  of  a  girl,  who  died  at  the  end  of  the  third  week,  and  whose 

n  English  Translation,     Vol.  I,  page  84.     1885.     Figs  4  and  5. 

b  Guy's  Hospital  Reports.     Third  Series.     Vol.  I.,  page  319.      1855. 


ENTERIC    FEVER. 


377 


bowels  had  been  confined,  that  the  small  intestines  were  filled  with 
hard  scybala,  and  that  there  was  an  nicer  underneath  each.  Louis, 
Jenner,  and  Hudson,  all  report  fatal  cases,  which  had  been  charac- 
terised by  persistent  constipation. 

According  to  Murchison,  diarrhoea  was  present  in  93  out  of  100 
cases  observed  by  him.  The  severity  and  danger  of  enteric  fever 
are  closely  related  to  the  intensity  of  the  diarrhoea.  But  to  arrive 
at  a  reliable  opinion,  it  is  necessary  to  inquire  of  the  nurses  in 
charge  what  they  understand  by  "  diarrhoea."  Sometimes  one 
profuse  evacuation  in  the  24  hours  may  well  be  termed  diarrhoea ; 
whereas,  on  the  contrary,  a  patient  may  be  disturbed  every  half 
hour  by  a  "  needing,"  when  only  a  little  mucus  and  fragments  of 
faeces  may  be  passed — not  sufficient  to  justify  the  application  of 
the  term  "diarrhoea."  The  discharges  have  a  heavy  putrid  and 
offensive  smell.  These  are  often  of  the  colour  of  yellow  ochre  and 
of  the  consistence  and  appearance  of  pea  soup.  If  allowed  to 
stand,  they  separate  into  two  strata — a  flaky  sediment  containing 
thin  faeces,  the  debris  of  sloughing  ulcers  (after  the  fourteenth  day), 
undigested  food,  and  many  prismatic  crystals  of  triple  phosphate, 
and  a  supernatant  yellowish  or  pale  brown  liquid,  alkaline  in 
reaction,  having  a  specific  gravity  of  1015,  and  containing  about  4 
per  cent,  of  solid  matter — chiefly  albumen  and  soluble  salts,  parti- 
cularly chloride  of  sodium.  Schbnlein,3,  in  1835,  first  observed 
triple  phosphate  in  the  dejecta  of  enteric  fever ;  but  they  are  not 
peculiar  to  it  and  their  presence  simply  means  that  decomposition 
is  rapidly  taking  place.  Other  kinds  of  enteric  stools  described  by 
Murchison  are — the  pultaceous,  frothy,  mudlike,  "  birdlime,"  bloody. 

Intestinal  haemorrhage  is  an  important  symptom.  Copious  bleed- 
ing (over  six  ounces)  occurred  in  58  of  1,564  cases  under  Murchi- 
son's  care — that  is,  in  3'77  per  cent.  Liebermeister's  estimate  of 
the  frequency  of  haemorrhage,  based  on  the  observation  of  1,743 
cases  of  enteric  fever  at  Basle,  is  7-3  per  cent.  Griesinger  observed 
32  cases  of  haemorrhage  in  600  enteric  fever  patients,  or  5-3  per 
cent.     Louis  found  bleeding  in  5*9  per  cent,  of  his  cases.     The 

a"Ueber  Crystalle  im  Darmcanal  bei  Typhus  abdominalis."  Muller's 
Archiv.,  1836. 


378  ENTERIC    FEVER. 

accident  may  occur  as  early  as  the  5th  or  6th  day,  when  it  is  probably 
caused  by  capillary  hyperemia  or  by  "  dissolution  of  the  blood." 
More  commonly,  hasmorrhage  is  not  seen  until  after  the  14th  day, 
when  it  is  most  likely  due  to  erosion  of  an  artery  at  the  ulcerated 
and  sloughing  base  of  one  of  Peyer's  patches.  Opinions  differ  as 
to  the  bearing  on  prognosis  of  intestinal  hasmorrhage.  Graves  and 
Henry  Kennedy  considered  that  in  certain  cases  it  was  of  marked 
benefit.  Graves  a  spoke  of  it  as  "  a  critical  discharge  of  blood  from 
the  bowels  "  not  to  be  unnecessarily  interfered  with.  Yet  he  saw 
four  patients  in  whom  the  occurrence  of  haemorrhage  from  the 
bowels  induced  death — "in  all  the  fever  had  a  marked  gastric 
character."  Trousseau,**  who  originally  held  the  view  that  these 
hemorrhages  are  serious  complications,  attracted  by  the  teaching 
of  Graves — "un  homme  d'une  aussi  grande  valeur,  d'une  aussi 
grande  renomm^" — changed  his  opinion  and  wrote: — "Pour  mon 
compte,  apres  m'etre  longtemps  range'  a  cet  avis,  je  professe  aujourd' 
hui  une  doctrine  tout  a  fait  opposee,  a  savoir,  que  les  hemorrhagies 
intestinales,  dans  la  fievre  typho'ide,  loin  d'avoir  la  gravite  qu'on  leur 
accorde,  constituent  le  plus  souvent  un  phenomene  de  favorable 
augure." 

On  the  other  side,  great  names  also  can  be  quoted,  especially 
those  of  Murchison  and  Liebermeister.  The  former  authority  no 
doubt  admits  that  a  moderate  bleeding  before  the  twelfth  day  may  do 
good  by  relieving  intestinal  congestion  ;  but  when  the  bleeding 
occurs  later  in  the  disease  and  is  profuse,  it  is  a  formidable  symp- 
tom. The  bleeding  makes  it  probable  that  the  ulceration  has  ex- 
tended to  the  vessels  beneath  the  transverse  muscular  fibres  of  the 
intestine,  and  such  ulceration  is  not  unlikely  to  go  on  to  perforation 
should  the  patient  survive  the  hasmorrhage.  Of  Liebermeister's 
own  cases,  38*6  per  cent,  died,  whereas  the  mortality  among  those 
without  hasmorrhage  was  only  11  per  cent.  This  author  admits 
that  his  statistics  are  not  quite  as  conclusive  as  they  at  first  sight 
appear,  for  in  some  fatal  cases  the  bleeding  is  in  no  way  respon- 

a  Clinical  Lectures.  New  Syd.  Soc.  Edition.  1884.  Vol.  I.,  pages  155 
and  156. 

fa  CUnique  M6d.  de  I'Hdtel  Dieu.     Paris.     1865.     Tome  I.,  p.  225. 


ENTERIC   FEVER.  379 

sible  for  the  result.  Ln  many  others,  however,  it  apparently  con- 
tributes to  the  production  of  cardiac  paralysis.  While,  therefore, 
intestinal  haemorrhage  must  be  regarded,  on  the  whole,  as  affecting 
the  prognosis  unfavourably,  yet  each  individual  case  must  be  judged 
on  its  own  merits.  According  to  Liebermeister,  further,  a  copious 
haemorrhage  early  in  the  disease  is  highly  unfavourable,  the  more 
so  as  it  contraindicates  the  use  of  one  of  the  most  valuable  thera- 
peutic agents  in  such  cases — to  wit,  cold  baths.  An  abundant 
haemorrhage  at  a  later  period — the  end  of  the  third  or  beginning 
of  the  fourth  week — though  not  without  danger,  may  do  good  by 
lowering  temperature  permanently. 

In  his  article  on  "  Abdominal  Typhus  "  in  the  Real  Encyclopddie 
der  gesammten  Beilkunde,  Dr.  W.  Zuelzer  says  that  in  the  intestine, 
the  bleeding  sometimes  fills  several  loops  of  intestine  so  full  that  the 
tympanitic  percussion  note  disappears.  From  this  we  are  often 
enabled  to  diagnosticate  latent  intestinal  haemorrhage.  To  the 
correctness  of  this  statement  I  can  testify  from  personal  observation. 

In  passing,  Liebermeister  remarks  that  the  frequency  of  intes- 
tinal haemorrhage  has  materially  diminished — from  8*4  per  cent, 
to  6-2  per  cent. — under  the  cold  water  treatment. 

Although  I  am  not  prepared  with  accurate  statistics  on  the 
point,  I  have  seen  many  cases  of  profuse  intestinal  haemorrhage 
in  enteric  fever,  and  the  impression  left  upon  my  mind  is  that 
an  unexpected  and  surprising  improvement  in  the  patient's  state 
sometimes  follows  one  copious  haemorrhage,  whereas  repeated 
haemorrhages  of  less  intensity  nearly  always  terminate  in  death. 

The  symptoms  of  intestinal  haemorrhage  are — sudden  or  rapidly 
increasing  prostration,  pallor,  quick  failing  pulse,  and  a  marked, 
even  if  temporary,  fall  of  temperature. 

The  spleen  is  very  constantly  enlarged  in  enteric  fever,  parti- 
cularly in  patients  under  30  years  of  age,  and  towards  the  close  of 
the  second  week  of  the  fever.  In  children,  Barthez  and  Rilliet a  met 
with  splenic  enlargement  in  28  out  of  105  cases.  Dr.  J.  C.  Wilson, 
the  writer  of  the  very  exhaustive  article  on  "  Enteric  or  Typhoid 

a  Traite  des  maladies  des  Enfans.     Paris.     1853.     Deuxifeme  Edition. 


380  ENTERIC   FEVER. 

Fever"'  in  Keating's  "  Cyclopaedia  of  the  Diseases  of  Children," a 
says  that  the  enlargement  of  the  spleen  is  so  frequent  and  so  con- 
siderable in  this  disease  that  it  has  acquired  a  certain  degree  of 
diagnostic  importance. 

The  spleen  enlarges,  as  a  rule,  downwards  and  forwards.  So 
long  as  the  organ  still  lies  inside  the  margin  of  the  ribs,  the 
enlargement  is  to  be  gauged  only  by  percussion.  When  the  spleen 
passes  below  the  ribs  and  invades  the  epigastric,  umbilical,  and 
left  lumbar  regions,  palpation  gives  accurate  information,  in  addi- 
tion to  percussion,  as  to  the  size,  shape,  and  consistence  of  the 
enlarged  viscus.  Weil's  diagram  of  splenic  enlargement  shows 
very  well  the  form  and  direction  which  this  pathological  condition 
takes.  Guttmann  b  points  out  that,  as  enlargement  of  the  spleen 
is  invariably  attended  by  increase  in  the  thickness  (the  antero- 
posterior diameter)  of  the  organ,  the  intensity  of  the  dulness  is 
always  much  greater  than  over  the  normal  spleen — the  percussion 
sound  of  a  large  splenic  tumour  is  as  absolutely  dull  as  that  heard 
over  the  liver,  while  the  sense  of  resistance  experienced  in  the 
percussing  finger  is  augmented  to  a  very  unusual  degree.  It  is  to 
be  remembered,  however,  that  extreme  tympanites  may  displace 
the  spleen  upwards  or  outwards. 

V.  The  Urinary  System. — During  the  first  week  or  ten  days 
the  urine  is  diminished  in  quantity,  is  dark  coloured,  acid,  of  high 
density  (Sp.  grav.  1025  to  1030),  and  contains  an  excess  of  urea  to 
the  amount  of  one-fifth  (Edmund  A.  Parkes),  and  of  uric  acid  also. 
According  to  Brattler,  quoted  by  Parkes,  there  is  a  close  corre- 
spondence between  the  amount  of  urea  and  the  temperature — the 
greater  the  amount  of  urea  the  higher  the  temperature.  This  view 
is  disputed  (see  page  278). 

After  the  second  week,  the  quantity  of  urine  increases  greatly  until 
convalescent,  when  80  or  90  ounces  may  be  passed  daily.  In  this 
second  period  the  urine  is  pale,  feebly  acid  or  alkaline,  and  of  low 
density — perhaps  only  1005  or  1003  in  convalescence  (Murchison). 

"Philadelphia  :  J.  B.  Lippincott  Company.     Vol  I.,  page  470.     1889. 
fc  Handbook  of    Physical    Diagnosis.      New    Syd.    Soc,    London.      1879. 
Vol.  LXXXIV.,  page  354. 


ENTERIC    FEVER.  381 

All  through  the  fever  chlorides  are  greatly  diminished  in 
quantity,  for  these  reasons — there  is  less  salt  taken  with  food,  much 
escapes  by  the  skin  in  perspiration,  there  is  a  good  deal  in  the 
motions  from  the  bowels,  and  lastly,  much  is  retained  in  the  system 
until  convalescence,  when  it  is  discharged  in  abundance. 

Albumen  is  less  frequently  present  in  the  urine  than  in  typhus, 
and  when  albuminuria  occurs,  it  does  so  later  in  the  disease. 

VI.  The  Nervous  System. — Neuralgic  and  rheumatoid  pains 
are  common  in  the  early  stages  of  enteric  fever.  When  these  pains 
are  articular,  the  case  may  at  first  simulate  acute  rheumatism. 
Vertigo  and  headache  are  common  symptoms — the  latter  is  most 
severe  during  the  first  week.  It  is  not  usually  very  intense,  but  it 
may  be  so.  In  the  Autumn  of  1890  I  attended  a  gentleman  who 
suffered  agony  from  headache  in  the  first  week  of  his  illness,  which 
ultimately  proved  fatal  from  the  supervention  of  the  ataxic  state. 
The  headache  is  generally  referred  to  the  forehead. 

Liebermeister  a  distinguishes  four  grades  of  nervous  disturbance, 
which  usually  occur  in  succession  in  severe  cases  of  enteric  fever. 

1.  In  the  earlier  part  of  the  first  week  the  nervous  symptoms  are 

malaise,   restlessness,  headache,  unfitness  for  mental   occupation, 
unquiet  sleep  with  dreams. 

2.  In  the  latter  part  of  the  first  and  the  beginning  of  the  second 
week,  the  patient  is  somewhat  apathetic,  his  sensations  are  blunted, 
and  his  memory  fails.  When  half  awake  and  not  thinking  of 
himself,  he  becomes  delirious.     At  other  times  his  mind  is  clear. 

3.  In  the  course  of  the  second  week,  through  the  third,  and  into 
the  fourth,  there  are — muttering  delirium,  a  drowsy  condition,  or 
even  sound  sleep,  from  which  the  patient  can  be  aroused  for  a  time, 
and  even  incited  to  exercise  his  volition.  \Coma  vigil  of  Jenner — 
Kcbfia  a<ypv7rvov  of  Hippocrates  and  Galen.]  Sometimes  the 
delirium  is  more  violent,  with  great  restlessness,  and  paroxysms 
of  intense  excitement,  approaching  mania. 

4.  In  the  worst  cases,  usually  in  the  third  week — rarely  earlier, 
not  infrequently  later — there  is  constant  loss  of  consciousness,  from 
which  the  patients  can  no  longer  be  aroused.     They  lie  without 

a  Von  Ziemssen's  Cyclopcedia  of  the  Pract.  of  Med.     Vol.  I.,  page  87.     1875. 


382  ENTEKIC   FEVER. 

any  evidence  of  mental  activity,  do  not  re-act  when  spoken  to  or 
shaken.  [This  state  is  the  Lethargus  (s.c.  morbus)  of  the  ancients — 
\7]6apyla,  drowsiness,  lethargy — Galen].  Hiccough  is  often  pre- 
sent in  this  condition  of  profound  nervous  prostration. 

The  disturbances  of  this,  the  highest,  degree  correspond  to  an 
almost  complete  abolition  of  the  functions  of  the  cerebrum,  and  when 
this  paralysis  extends  to  the  medulla  oblongata  it  leads  to  death.    ■ 

In  a  paper  on  "  Reflex  Actions,  Knee-jerks,  and  Muscular  Irri- 
tability in  Typhoid  Fever,  Phthisis,  and  other  Continuous  Fevers," 
Dr.  Angel  Money  a  points  out  that  in  all  cases  of  enteric  fever  the 
knee-jerk  is  exaggerated,  so  much  so  that  its  equivalent  (contrac- 
tion of  the  quadriceps  extensor  femoris)  may  often  be  produced  by 
drawing  down  the  patella  with  tbe  forefinger,  and  then  percussing 
the  straining  forefinger — a  method  which  Dr.  Money  first  learned 
from  Dr.  Gowers.  He  also  finds  that  muscular  irritability  is 
greatly  increased  in  this  fever,  and  this  increase  shows  itself  in 
several  ways.  "When  a  muscle  is  tapped  by  immediate  percussion 
with  the  finger  or  stethoscope  a  contraction  of  the  whole  muscle  is 
brought  about,  and  at  the  same  time  a  series  of  fibrillary  contrac- 
tions occur  in  the  belly  of  the  muscle.  These  conditions  are  best 
observed  in  a  voluminous  muscle  like  the  calf.  The  facial  muscles 
are  not  so  irritable,  though  occasionally  percussion  over  or  about 
the  malar  process  may  cause  a  very  obvious  contraction  of  the 
orbicularis  palpebrarum.  The  tongue  shows  fibrillary  tremors  rather 
earlier  than  the  trunk  and  limb  muscles.  When  the  knee-jerks 
are  greatly  exaggerated,  as  they  sometimes  are  in  enteric  fever, 
fibrillary  contractions  of  the  muscles  occur,  and  spontaneous  con- 
tractions of  the  whole,  or  nearly  the  whole,  of  the  muscles  are  not 
infrequently  present.  These  are,  of  course,  well  known  under  the 
name  of  "  subsultus  tendinum."  When  this  marked  degree  of 
irritability  exists,  "ankle  clonus"  is  usually  present  and  is  easily 
elicited. 

VII.  The  Organs  of  Special  Sense. 

1.  The  Eye  is  clear  and    bright,  and  the  pupils   are  usually 
dilated,  indicating  ansemia  of  the  eye.     In  great  stupor  and  coma 

"     a  Lancet.     1885.     VqI.  II.,  page  842.     November  7. 


ENTERIC   FEVER.  383 

the  pupils  are,  however,  often  contracted,  and  the  eyes  are  hyper- 
semic  or  congested. 

2.  The  Ear. — Buzzing  noises  are  often  complained  of  in  the 
early  stages,  and  deafness  of  one  or  both  ears  is  a  common  symptom 
later  on — towards  the  close  of  the  second  week  and  onwards. 
Louis  observes  :  "  La  plus  extreme  surdity  n'ajoute  rien  a  la  gravite" 
du  pronostic."  Murchison  does  not  quite  agree  in  this  opinion. 
Bilateral  deafness  may  be  caused  by  catarrh  of  the  Eustachian 
tubes.  The  remarks  already  made  on  the  deafness  of  typhus  apply 
to  this  symptom  in  enteric  fever  also. 

3.  The  Nose. — Epistaxis  or  nose-bleeding  is  a  very  common 
symptom,  especially  in  children.  Rilliet  and  Barthez  met  with  it 
in  one-fifth  of  their  107  cases.  It  may  take  place  at  any  time  in 
the  fever,  and  may  recur  again  and  again  so  as  to  produce  extreme 
anaemia  or  not  seldom  to  destroy  life. 

4.  Cutaneous  sensibility.  — Hyperesthesia  of  the  surface  was 
noticed  by  Murchison  in  about  5  per  cent,  of  his  cases.  It  is  most 
common  in  women  and  children,  and  is  not  generally  of  grave 
importance.  It  is  best  marked  over  the  abdomen  and  lower  limbs, 
a  fact  which  may  lead  to  an  error  in  diagnosis — the  tenderness  on 
pressure  due  to  peritonitis  being  mistaken  for  mere  hyperesthesia, 
or  vice  versa. 

VIII.  Emaciation  is  a  very  marked  and  characteristic  symptom 
in  enteric  fever.  Its  causes  are :  the  prolonged  illness,  the  special 
implication  of  the  digestive  system  in  the  morbid  process,  and  the 
wasting  nature  of  the  discharges.  Recently  (October,  1891),  a 
notable  example  of  marasmus  after  a  protracted  enteric  fever  was 
under  my  care  in  the  wards  of  the  Meath  Hospital  in  the  person 
of  a  little  girl  aged  twelve  years,  who  is  almost  literally  only  "skin 
and  bone."     The  patient  has  since  recovered. 


384 


CHAPTEK   XXXIX. 
Eel  apse  in  Enteric  Fever. 

'  Relapse  is  a  rare  occurrence — Definition  of  True  Relapse — Relapses  not  to 
be  confounded  with  Recrudescences— Clinical  Record  of  a  case  of  Relapse- 
Statistics  of  Occurrence  of  Relapse — Relapse  not  so  dangerous  as  the  first 
attack — ^Etiology  of  Relapse — Probable  influence  of  :  (1.)  Constipation  ;  (2.) 
Enlargement  of  the  Spleen. 

Among  the  many  causes  of  renewed  pyrexia,  or  feverisliness,  in  the 
later  stages  of  enteric  fever,  or  in  convalescence  from  this  disease, 
true  relapse  necessarily  occupies  a  foremost  place.  And  this  arises, 
not  so  much  from  any  increased  danger  to  the  patient's  life — which 
is  theoretical  rather  than  founded  on  fact— as  from  the  comparative 
infrequency  of  the  occurrence  of  true  relapse  in  this  form  of  con- 
tinued fever. 

By  "  true  relapse"  I  understand  a  second  attack,  in  which  the 
characteristic  phenomena  of  enteric  fever  present  themselves  in 
sufficient  number  to  establish  the  diagnosis  of  the  disease— for 
example,  enlargement  of  the  spleen,  abdominal  tenderness,  ochrey 
diarrhoea,  and  rose  spots  ;  or  epistaxis,  feverishness  with  evening 
exacerbations,  abdominal  tenderness  and  tympanites  ;  or  any  other 
grouping  of  the  symptoms  of  this  fever  met  with  in  practice ;  the 
fact  being  admitted  that  a  perfectly  typical  case  of  primary  enteric 
fever,  showing  all  the  characters  of  the  disease,  does  not  often  come 
under  observation,  even  in  the  wards  of  a  large  epidemic  hospital. 
"By  a  relapse  of  enteric  fever,"  writes  Murchison,a  "is  understood 
a  second  evolution  of  the  specific  febrile  process,  after  convalescence 
from  the  first  attack  is  fairly  established.  Relapses  must  not  be 
confounded  with  the  recrudescences,  which  are  common  during  the 
stage  of  ulceration." 

&The  Continued  Fevers  of  Great  Britain.  Third  Edition.  Edited  by  W. 
Cayley,  M.D.,  F.R.C.P.     London  :  Longmans,  Green  &  Co.    1884.   Page  552. 


ENTERIC    FEVER.  385 

I  will  detail  the  salient  points  in  a  case  which  falls  within  the 
limits  of  the  foregoing  definition,  and  which  I  communicated  to  the 
Royal  Academy  of  Medicine  in  Ireland  in  1885a : — 

On  Saturday,  January  24,  1885,  Mrs.  Mary  B.,  aged  twenty,  a 
domestic  servant,  was  admitted  into  Cork-street  Fever  Hospital, 
under  my  care,  at  the  request  of  the  late  Dr.  S.  M.  MacSwiney, 
F.K.Q.C.P.,  who  had  been  called  to  see  her  when  she  was  already 
several  days  ill,  and  who  recognised  her  ailment  as  enteric  fever. 
She  had  been  married  not  long  previously,  but  menstruation  was 
regular  up  to  the  time  of  her  illness,  and  there  was  no  reason  to 
believe  that  she  was  pregnant. 

When  I  visited  the  hospital  on  the  morning  of  the  25th  I  found 
that  Mrs.  B.  had  complained  of  weakness  and  chilliness  nine  days 
before.  Diarrhoea  soon  set  in,  for  which  she  was  treated  by  a  re- 
spectable general  practitioner,  who  was  at  the  disadvantage  of  seeing 
the  patient  up  and  dressed,  and  so  failed  to  recognise  the  true 
nature  of  the  case.  At  last  she  took  to  bed,  and  was  seen  by  Dr. 
MacSwiney,  who  advised  her  removal  to  hospital. 

At  my  first  visit,  her  pulse  was  120,  respirations  32,  and  tem- 
perature (10  a.m.)  103  2°.  The  area  of  splenic  dulness  was  enlarged. 
There  was  a  good  deal  of  tympanites,  and  some  tenderness  on 
pressure  existed  in  the  iliac  fossae.  She  was  passing  from  four  to 
six  yellowish  fluid  motions  in  the  twenty-four  hours.  There  was 
insomnia,  and  her  mental  state  was  unsatisfactory — nervous  and 
excited.  Crepitating  rales  were  audible  over  the  back  of  both 
lungs.  Several  typical  rose-spots  were  detected  on  the  trunk,  and 
also  some  taches  bleuatres.  A  glycerine  and  laudanum  poultice 
was  applied  to  the  abdomen.  The  back  of  the  chest  was  drycupped- 
She  was  ordered  ice,  milk  and  arrowroot,  and  6  ozs.  of  port  wine. 
Chalk  mixture,  with  chlorodyne  and  compound  tincture  of  chloro- 
form, was  prescribed,  as  well  as  a  full  dose  of  Dover's  powder  at 
bedtime.  Next  day  the  chest  was  poulticed  with  linseed  meal 
sprinkled  with  powdered  camphor,  and  on  the  27th  3-grain  doses 
of   quinine    were    given  thrice   a  day.     On  the  28th   turpentine 

a  Trans,  of  the  Acad.  Med.  in  Ireland.  Vol.  IV.,  page  1.  1886.  See  also 
Dub.  Journ.  Med.  Science.     Vol.  LXXX.,  page  486.     December,  1885. 

2    C 


386  ENTERIC    FEVER. 

fomentations  were  applied  to  both  chest  and  abdomen,  and  on  the 
29th  a  further  increase  of  diarrhoea  required  the  administration  of 
an  enema  containing  12  minims  of  tincture  of  opium  in  two  ounces 
of  mucilage  of  starch. 

On  January  30,  the  15th  day  of  the  fever,  the  patient  appeared 
to  be  going  on  well— P.  106,  R.  26,  T.  101-8°  in  the  forenoon, 
rising  only  to  102'6°  in  the  evening.  At  night  some  intestinal 
haemorrhage  occurred.  Next  morning  a  poultice  of  crushed  ice  was 
applied  to  the  abdomen,  and  three  grains  of  ergotin  were  ordered 
to  be  injected  hypodermically  should  haemorrhage  recur.  This  did 
not  happen,  and  the  patient  began  to  make  excellent  way ;  her 
pulse  and  respirations  fell  and  diarrhoea  ceased,  giving  place  to 
obstinate  constipation— a  point  of  some  moment  in  the  light  of  the 
subsequent  history  of  the  case.  Reference  to  the  clinical  chart  will 
show  that  from  the  16th  to  the  23rd  days  of  the  fever  inclusive  the 
evening  exacerbations  of  pyrexia  were  very  marked,  the  tempera- 
ture being  from  3°  to  4°  higher  than  in  the  forenoons. 

On  the  morning  of  February  8  (24th  day)  the  body  was  covered 
with  a  plentiful  crop  of  sudamina,  but  the  temperature  was  only 
98°.  The  following  evening  it  did  not  exceed  100-1°,  and  48  hours 
afterwards  it  became  permanently  normal. 

Mrs.  B.  remained  in  hospital  until  February  28,  when  she  was 
sent  to  the  Convalescent  Home,  Lynden,  Blackrock,  Co.  Dublin, 
this  being  the  18th  day  of  complete  apyrexia  and  the  44th  day  from 
the  commencement  of  her  illness.  During  the  last  three  weeks  of 
her  stay  in  hospital  the  bowels  were  obstinate,  and  had  to  be 
kept  in  order  by  the  almost  periodic  use  of  simple  enemata  or 
the  occasional  administration  of  castor-oil  in  small  and  repeated 
doses. 

During  the  first  few  days  of  her  stay  at  the  Convalescent  Home, 
Mrs.  B.  made  satisfactory  progress.  Her  stomach  then  became 
irritable ;  she  lost  her  appetite,  began  to  cough,  and  felt  hot  and 
cold  by  turns.  She  came  into  Dublin,  and  in  the  course  of  a  few 
days  called  to  see  me.  I  found  her  tongue  furred  and  her  pulse 
quick.  There  were  few,  if  any,  physical  signs  of  chest  affection, 
but  she  looked  pale  and  thin,  like  one  who  would  readily  run  into 


ENTERIC    FEVER.  387 

acute  consumption.  Acting  under  my  advice,  she  went  home  to 
bed,  and  I  visited  her  on  Thursday,  March  19,  the  twelfth  day 
from  the  appearance  of  symptoms  of  her  second  illness.  Her  pulse 
at  5  p.m.  was  108,  and  her  temperature  was  103°. 

Next  day  she  was  again  admitted  to  Cork-street  Hospital,  under 
my  care.  The  morning  temperature  was  only  99*1°,  but  in  the 
evening  the  thermometer  marked  1028°  in  the  axilla.  There  was 
some  increased  splenic  dulness  on  percussion,  and  a  few  rose-spots 
were  found  on  the  chest  and  abdomen.  On  this  and  the  three 
following  days  there  was  a  tendency  to  diarrhoea — two  or  three 
yellow  soft  motions  occurring  each  day.  Afterwards  the  bowels 
acted  regularly  once  a  day.  The  course  of  this  second  fever  is 
sufficiently  well  shown  on  the  temperature  chart  (Plate  VIIL,  Fig.  4). 
It  will  be  seen  that  there  was  a  well-marked  l-emittent  tendency  in  the 
temperature  range — the  morning  readings  were  moderate  or  low, 
while  the  evening  ones  were  between  102°  and  103°.  On  the  20th 
day,  although  the  pulse  remained  steady  at  88,  the  temperature  rose 
from  980°  in  the  forenoon  to  1026°  in  the  evening.  A  somewhat 
similar  rise  next  day  was  succeeded  by  a  rapid  defervescence,  which 
was  completed  in  three  days,  and  so  more  completely  resembled  a 
crisis  than  is  usual  in  enteric  fever.  At  this  time,  also,  the  pulse 
fell  below  normal,  beating  from  66  to  76  times  a  minute. 

It  is  only  necessary  to  add  that  Mrs.  B.  made  a  quick  and 
satisfactory  recovery;  all  chest  symptoms  subsided,  her  appetite 
returned,  and  she  speedily  regained  her  wonted  health  and  strength. 
On  the  31st  of  March  (the  24th  day  of  her  second  illness)  she 
was  transferred  to  the  care  of  my  friend,  Dr.  J.  M.  Redmond, 
F.R.C.P.I.,  who  then  succeeded  me  as  Physician  to  Cork-street 
(Fever)  Hospital,  and  on  the  15th  of  April  she  left  hospital,  finally 
convalescent.  During  the  last  ten  days  of  her  stay  in  hospital 
there  was  again  some  little  trouble  from  constipation. 

The  foregoing  case  suggests  some  interesting  points  for  discus- 
sion. In  the  first  place,  there  seems  little  reason  to  doubt  that  it 
affords  an  example  of  true  relapse  in  enteric  fever,  as  distinguished 
from  a  secondary  symptomatic  pyrexia  occurring  in  convalescence 
from  that  disease,  and  due  to  one  or  other  of  the  recognised  causes 


388  ENTERIC   FEVER. 

of  such  a  sequela — septicaemia,  enteritis,  pneumonia,  acute  tuber- 
culosis, and  so  on.  In  the  case  before  us,  there  was  a  long  period 
of  apyrexia — twenty-four  days — between  the  two  fevers,  the  second 
of  which,  no  less  than  the  first,  presented  a  grouping  of  symptoms 
sufficient  to  warrant  the  diagnosis  of  enteric  fever.  "  It  is  on  the 
presence  of  the  eruption,  and  on  the  absence  of  any  local  inflamma- 
tion to  account  for  the  pyrexia,  that  the  diagnosis  of  a  true  relapse 
niust  be  based."— (Murchison). 

This  being  so,  the  case  demands  attention  because  of  the  rarity 
of  relapse  even  in  this  form  of  continued  fever.  Murchison  a  states 
that,  during  seven  years  (1862-68),  relapses  were  observed  in  80 
of  2,591  cases  in  the  London  Fever  Hospital — that  is,  in  3  per 
cent.  Griesinger  noted  them  in  6  per  cent,  of  463  cases  at  Zurich; 
Human  in  8  per  cent,  of  548  cases  at  Leipzig ;  and  Maclagan  in 
13  (10  per  cent.)  of  128  cases  at  Dundee. 

Relapse  occurred  in  21  cases  out  of  129  observed  by  Dr.  F.  C. 
Shattuck,  of  Harvard  University  (16*28  per  cent).  In  one  case 
there  was  a  second  relapse.  The  duration  of  the  second  attack 
varied  from  11  to  29  days,  the  average  being  19  days.  There  was 
only  one  death.     Treatment  was  expectant. 

Jaccoud  considers  that  relapses  are  much  more  frequent  in 
enteric  fever  than  is  usually  believed.  He  has  seen  more  than  60 
caSes — between  9  and  10  per  cent,  of  his  personal  statistics  in  the 
wards  of  La  Pitie  and  in  private  practice. 

Eichhorst  collected  statistics  of  six  hundred  and  sixty-six  cases 
of  enteric  fever  treated  at  Zurich  during  three  years.  He  found 
that  a  second  attack  occurred  in  4-2  per  cent.  (28  persons).  Men 
are  more  liable  to  relapse  than  women.  The  severity  and  fatality 
of  the  relapse  equalled  that  of  the  first  attack. 

As  compared  with  typhus,  in  which  true  relapse  is  one  of  the 
rarest  events,  in  clinical  observation,  these  are  all  relatively  high 
percentages.  Out  of  18,268  cases  of  typhus  reported  at  the  London 
Fever  Hospital  during  23  years,  there  is  only  one  instance  of  a  true 
relapse,  although  in  several  instances  a  genuine  has  been  preceded 
by  an  abortive  attack.15 

a  Murchison.     Loc.  cit.,  page  552.  b  Murchison.     Loc.  cit.,  page  189. 


ENTERIC    FEVER.  389 

Again,  it  is  worth  noting  that  in  the  case  I  have  just  detailed 
the  relapse  ran  a  milder  and  slightly  shorter  course  than  the 
preliminary  attack.  The  first  fever  terminated  on  the  twenty- 
seventh  day.  Then  came  an  apyrexial  period  of  24  days — from 
the  11th  of  February  to  the  7th  of  March — and  this  was  lastly 
followed  by  a  fever  which  ran  a  twenty-four  days'  cour.se.  All  this 
is  in  accordance  with  clinical  experience.  Thus,  Murchison  says 
that  the  duration  of  the  second  attack  is  usually,  but  not  neces- 
sarily, shorter  and  milder  than  that  of  the  first.a  Of  24  cases 
collected  from  various  sources  by  Michel,  the  mean  duration  of  the 
first  attack  was  27  clays;  of  the  intermission,  11  days  (shortest  2 
and  longest  31  days) ;  and  of  the  relapse — shortest,  16  days  ;  longest, 
30.  In  53  cases  which  came  under  Murchison's  own  observation, 
and  which  he  has  tabulated,  the  average  duration  was — of  the  first 
attack,  27'0  days;  of  the  intermission,  H'76  days;  and  of  the 
relapse,  16*4  days.  It  is  noteworthy  that  of  these  53  patients  only 
5  died  in  the  relapse,  the  mortality  being  at  the  rate  of  9  4  per  cent, 
compared  with  17*26  per  cent,  in  primary  attacks  in  5,911  cases 
admitted  into  the  London  Fever  Hospital.  From  this  it  would 
appear  that  a  relapse  is  only  about  half  as  dangerous  to  life  as  a 
first  attack. 

The  last  point  to  be  considered  is  the  probable  aetiology  of  relapse 
in  enteric  fever.  In  1846  Hamernjk  put  forward  the  view  that 
relapse  was  due  to  reabsorption  of  the  "  typhous  material "  thrown 
off  by  the  patient's  own  bowel. b  Dr.  T.  J.  Maclagan  adopts  this 
view,  believing  that  the  surviving  healthy  glands  become  inocu- 
lated by  the  sloughs  thrown  off  from  those  first  affected.  In 
accordance  with  this  theory,  Maclagan  further  holds  that  relapses 
are  met  with  only  when  there  has  been  constipation  in  conva- 
lescence. This  condition  was  certainly  present  in  Mrs.  B.'s  case, 
and  we  are  justified  in  assuming  that  the  non-elimination  of  the 
fever  poison,  owing  to  constipation,  was  at  all  events  one  factor, 
and  that  an  important  one,  in  the  causation  of  the  second  attack. 

a  Murchison.     Lnc.  cit.,  page  553. 

b  Murchison.     Loc.  cit.,  page  555  ;   and  Hamernjk,  Prag.  Vierteljahrssch. 
1846.     X.  I.  (Zur  Pathologic  unci  Diagnose  cles  Typhus). 


390  ENTERIC   FEVEK. 

It  may  be  objected  that  to  adopt  this  view  in  its  entirety  is  to 
pledge  ourselves  to  the  exploded  theory  of  the  local  origin  of  the 
phenomena  of  enteric  fever — is  to  revert  to  Broussais'  doctrine, 
according  to  which  the  pyrexia  of  the  disease  is  the  result  of  a 
local  inflammation  of  the  intestinal  glands.  But  this  is  not  stated. 
What  we  hold  is  that,  as  a  result  of  constipation,  the  fever  poison 
finds  no  exit  from  the  system  via  the  bowels,  it  is  then  absorbed 
by  the  glands  which  have  hitherto  escaped  the  characteristic 
secondary  inflammation  of  the  disease,  and  passing  into  the  blood 
once  more  sets  up  an  essential,  not  a  symptomatic,  fever. 

One  other  theory  of  relapse  may  be  drawn  from  the  analogy  of 
true  relapsing,  or  spirillum,  fever.  In  the  third  volume  of  the 
frisk  Hospital  Gazette  (April  1,  1875,  page  105),  Dr.  Gerald  F. 
Yeo  quotes  from  the  Centralblatt  fur  klinische  Medicin  an  observa- 
tion of  Dr.  M.  Laptachinski,  that  with  each  attack  of  pyrexia  in 
spirillum  fever  a  discharge  of  the  spleen  contents  into  the  blood 
takes  place.  From  observation  of  the  epidemic  of  relapsing  fever 
of  1847-49  in  Ireland,  Dr.  Alfred  Hudson,  then  of  Navan.  Co. 
Meath,  was  led  to  believe  in  the  frequent  co-existence  of  the  poison 
of  endemic  typhoid  with  that  of  epidemic  relapsing  fever — the  one 
disease  replacing  the  other  in  the  same  patient. 

He  also  noticed  the  influence  upon  the  blood  of  the  reabsorption 
into  the  circulation  of  a  quantity  of  depraved  blood,  laid  up,  as  it 
were,  in  the  congested  spleen,  and  commingling  with  the  circulating 
mass  after  crisis,  in  the  purifying  effect  of  which  it  had  not  shared. 
He  adds  : — "  I  shall  be  mistaken  if  future  observations  do  not  prove 
this  to  be  an  important  element,  not  only  in  the  production  of 
relapse,  but  also  in  determining  the  enteric  lesions,  which  occur  during 
the  second  and  third  attacks,  in  this  form  of  fever."  b  Remembering 
how  constantly  the  spleen  is  enlarged  and  congested  in  enteric 
fever,  we  may  perhaps  apply  to  this  disease  also  the  ingenious 
pathological  hypothesis  which  was  first  advanced,  as  we  have  seen, 
by  Dr.  Hudson,  in  explanation  of  the  relapses  in  spirillum  fever. 

Towards  the  close  of  the  year  1886,  I  met  with  another  instance 

h  Lectures  on  the  Study  of  Fever.  Second  Edition.  1868.  Pages  147  and 
287. 


ENTERIC    FEVER.  301 

of  true  relapse  in  enteric  fever,  in  the  person  of  a  member  of  the 
medical  profession — a  gentleman  aged  thirty-two  years.  The 
temperature  in  this  case  is  given  in  Fig.  5  of  Plate  VIII.  The 
primary  attack  lasted  exactly  28  days,  and  was  followed  by  a  week 
of  apyrexia,  during  which  the  bowels  were  confined.  On  the 
thirty-fifth  day  rigors  occurred  in  the  afternoon,  and  temperature 
rose  to  104°  within  30  hours.  This  new  fever  lasted  14  days,  and 
was  accompanied  by  a  fresh  but  scanty  crop  of  rose-spots  from  the 
seventh  day  onwards. 


392 


CHAPTER  XL. 

Enteric  Fever  {continued). 

Temperature — Complications  and  Sequelae. 

Temperature  important  in  diagnosis  and  prognosis. — Initial  or  Prodromal 
Stage  :  remittent  type. — Fastigium  :  continuous  type. — Amphibolic  Stage. — 
Defervescence  :  remittent  type  with  "  spiking." — Test  of  complete  recovery. — 
Remittent  type  of  pyrexia  in  young  children  — Moderate  pyrexia  in  old 
patients. — Apyrexial  or  Afebrile  Enteric  Fever.  Complications  and  Sequels  : 
of  respiratory  tract,  the  circulation,  the  nervous  system,  organs  of  special  sense, 
digestive  tract,  the  urinary  organs,  female  organs  of  generation,  tissues,  integu- 
ments, and  bones;  marasmus,  sudden  death. — Coexistence  of  other  specific 
diseases. 

Temperature. — The  most  comprehensive  account  of  the  be- 
haviour of  the  temperature  in  enteric  fever  is  that  given  by 
Wunderlich.  from  whose  monograph  on  "  Temperature  in  Diseases  " 
I  have  so  often  quoted  in  this  book.  He  remarks  that  the  presence 
of  this  disease  can  be  decided  by  the  temperature  only  when  both 
morning  and  evening  temperatures  have  been  taken  for  several  days. 
In  the  beginning  of  the  fever  about  three  days'  observations  are 
required  for  the  purpose  of  diagnosis  ;  but  in  the  fastigium  and  in 
convalescence  from  four  to  six  days'  record  is  requisite. 

Thermometrical  observations  have  also  an  important  bearing  on 
prognosis  in  this  disease.  In  the  second  week  the  severity  of  a  case 
is  commonly  indicated  by  the  temperature  alone.  The  thermo- 
meter further  enables  us  to  recognise  irregularities  in  the  course  of 
the  fever,  the  advent  of  complications,  a  recrudescence  or  a  relapse, 
a  tendency  to  death,  the  effects  of  treatment,  and  the  transition  to 
convalescence. 

Enteric  fever  is  characterised  by  a  fever-movement,  which  lasts 
for  at  least  three  weeks,  unless  in  exceptional  cases,  and  in  those 
which  prove  fatal  at  an  early  stage.  The  maximal  temperature, 
as  a  rule,  is  not  less  than  103*3°  F.,  and  is  more  commonly  between 


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ENTERIC    FEVER,  &>3 

104°  and  10o'8°.  It  may  rise  to  hyperpyretic  degrees,  but  not 
easily  above  110°.  In  one  of  Dr.  Reuben  J.  Harvey's  cases — that 
of  a  young  woman,  aged  twenty,  who  died  in  Cork-street  Hospital 
on  March  17,  1880,  apparently  on  the  eighteenth  day  of  ataxic 
typhoid  fever — the  temperature  in  the  axilla  a  few  minutes  before 
death  registered  lO^S0.  The  chart  is  given  in  Plate  VIII.,  Fig.  7. 
Except  in  fatal  cases,  however,  it  is  rare  to  meet  with  temperatures 
above  106-7°. 

At  the  beginning  the  temperature  rises  in  a  zig-zag  fashion, 
in  such  a  way  that  during  the  four  days  or  so  occupied  by  the 
pyrogenetic  or  initial  stage  the  thermometer  rises  about  2°  or 
2#5°  Fahr.,  from  morning  to  evening,  falling  again  from  evening 
to  morning  only  1°,  or  at  most  1'5°  Fahr.,  with  the  result  that 
about  the  fourth  evening  a  reading  of  104°  is  reached  or  slightly 
exceeded. 

From  this  time  onward  for  seven  or  eight  days,  the  course  of 
the  temperature  is  tolerably  uniform — slight  morning  remissions 
being  followed  by  moderate  evening  exacerbations  in  this  stage, 
the  fastigium  of  the  fever. 

It  will  be  observed  that,  so  far,  we  have  had  to  deal  with  a 
remittent  type  of  fever  during  the  pyrogenetic  stage,  and  a 
continuous  or  sub-continuous  type  during  the  fastigium. 

In  the  middle  of  the  second  week,  between  the  9th  and  12th 
days,  slight  and  severe  cases  show  a  marked  difference. 

In  slight  cases  the  fastigium  then  shows  a  tendency  to  terminate — 
its  short  daily  curves  are  gradually  converted  into  the  steep  daily 
curves  of  the  period  of  convalescence.  The  temperature  ranges  begin : 
to  "spike,"  and  the  fever-type  is  once  more  remittent.  In  such 
cases  the  temperature  approaches  to  normal  in  a  zig-zag  fashion 
in  the  course  of  from  6  to  10  days  :  defervescence  is  gradual — by 
lysis.  Recollect,  however,  that  even  in  these  mild  cases,  at  any 
moment  the  even  tenor  of  the  temperature  range  may  be  inter- 
rupted by  the  supervention  of  some  complication. 

We  may  expect  a  severe  course  of  the  fever  when  the  morning 
temperature  is  persistently  above  103°,  and  the  evening  temperature 
touches  105°,  when  any  irregularity  of  temperature  occurs  in  the 


394  ENTERIC   FEVER. 

second  week,  when  moderation  of  the  temperature  does  not  occur, 
at  least  about  the  twelfth  day.  Increasing  fever  towards  the  close 
of  the  second  week  is  always  an  ominous  sign  of  coming  trouble. 
The  same  remark  applies  to  a  rising  temperature  in  the  third  week, 
or  to  a  temperature  which  is  higher  in  the  third  than  it  was  in  the 
second  week.  Complications  commonly  occur  about  this  time. 
They  generally  raise  the  temperature,  and  abolish  or  mask  the 
morning  remissions.  Profuse  haemorrhage  or  perforation  of  the 
intestine  may  cause  sudden  and  considerable  fall  of  temperature. 

In  these  severe  cases,  a  period  of  changing  fortunes — a  period  of 
uncertainty — often  intervenes.  This  is  called  the  amphibolic 
stage,  and  has  already  been  explained  (see  page  366).  It  some- 
times lasts  only  three  or  four  days ;  generally  a  week,  or  ten  days, 
sometimes  even  longer. 

In  fatal  cases,  in  the  death  agony,  or  at  the  moment  of  death, 
the  temperature  may  be  subnormal,  but  more  usually  it  is  high  or 
excessive— 107-6°  to  110°. 

Sometimes  the  amphibolic  stage  terminates  in  a  protracted  fever 
(lentescirende  Process — Wunderlich),  of  quite  indefinite  duration  and 
depending  upon  continued  ulceration  in  the  bowels,  or  bronchorrhoea, 
or  marasmus. 

Although  defervescence  generally  takes  place  gradually  in  enteric 
fever — that  is,  by  lysis,  yet  it  may  occur  suddenly — that  is,  by 
crisis.  Dr.  H.  T.  Bewley,  F.R.C.P.I.,  has  kindly  permitted  me  to 
publish  a  clinical  chart  of  such  a  case.     (See  Plate  VIII.,  Fig.  9.) 

Complete  recovery  is  to  be  admitted  only  when  the  temperature 
shows  complete  freedom  from  fever  in  the  evenings — when,  in  fact, 
it  has  been  normal  for  at  least  two  successive  evenings.  For  a 
short  time  the  thermometer  may  fall  below  normal,  but  trivial 
causes — such  as  change  of  diet,  excitement,  and  so  on — may  cause 
it  to  rise  afresh  from  time  to  time  in  convalescence. 

Young  children  show  a  very  remittent  type  of  temperature  in 
enteric  fever.  In  middle-aged  and  elderly  subjects,  the  intensity 
of  the  fever  as  marked  by  the  thermometer  is  less  pronounced  than 
it  is  in  children  and  adolescents. 

Dr.  Cayley  supplements  Murchison's  account  of  the  behaviour  of 


ENTERIC    FEVER. 


395 


the  temperature  in  the  disease  by  a  paragraph  on  apyrexial  or 
afebrile  enteric  fever.     He  writes  : — 

"  Cases  or  even  epidemics  of  Enteric  Fever  have  been  observed 
in  which  the  temperature  throughout  has  not  risen  above  the  normal 
point,  and  has  often  been  subnormal,  though  the  disease  has  been 
of  a  severe  type,  with  weli-marked  intestinal  lesions.  This  ab- 
normal range  of  temperature  seems  to  have  always  been  due  to 
the  patients  having  previously  been  exposed  to  great  hardships 
and  insufficient  food." — (Murchison's  "  Treatise  on  the  Continued 
Fevers."     1884.     Page  518.) 

An  epidemic  of  this  kind  is  described  by  Dr.  Struve  as  having 
occurred  among  the  German  troops  besieging  Paris  in  1870,  and 
another  similar  epidemic  was  recorded  by  Dr.  O.  Frantzel  in  the 
Zeitschrift  fur  klin.  Medicin  for  1880. 

Complications  and  Sequelae. 

1.  The  Eespiratory  Tract. — 1.  Bronchitis  is  rarer  in  enteric 
fever  than  it  is  in  typhus.  Murchison  noted  its  presence  in  21 
out  of  100  cases.  It  may  occur  early  or  late  in  the  fever,  but 
most  commonly  both  bronchitis  and  hypostatic  consolidation  of 
the  lungs  supervene  in  the  fourth  week,  when  these  complications 
either  kill  or  indefinitely  prolong  convalescence. 

2.  Pneumonia  is  more  common  than  in  typhus.  Murchison 
noted  it  in  13  out  of  100  cases,  and  Austin  Flint  (according  to 
P>artletta)  in  12  out  of  73  cases.  It  commonly  occurs  in  the  third 
or  fourth  week,  but  may  usher  in  the  disease.  In  this  latter  case 
its  presence  is  probably  an  indication  that  the  enteric  fever  poison 
has  entered  the  system  through  the  lungs.  It  is  most  commonly  a 
lobular  pneumonia,  but  occasionally  it  occurs  under  the  form  of 
croupous  pneumonia.  When  there  is  an  unusual  tendency  to 
pneumonia  and  pleurisy  in  enteric  fever,  the  disease  receives  the 
name  of  the  "thoracic  form." 

3.  Pleuritis  is  more  usual  than  in  typhus.  It  may  terminate  in 
empyema,  or  in  an  interlobar  pleural  abscess  (Murchison).  Pleurisy 
was  observed  in  the  hospital  at  Basle  64  times  in  1,743  cases  of 
enteric  fever.     Twenty-one  of  the  64  cases,  or  nearly  one-third, 

"  The  Fevers  of  the  United  States.     Fourth  Edition.     Philadelphia.     1856. 


396  EXTERIC   FEVER. 

terminated  fatally.  In  most  of  the  fatal  cases  (14)  the  pleurisy 
was  dependent  upon  some  affection  of  the  lungs — such  as  hemor- 
rhagic infarction,  gangrene,  pneumonia  (Liebermeister). 

4.  Pulmonary  Tubercle  is  a  more  common  sequel  of  enteric 
fever  than  of  typhus.  This  is  due,  according  to  Murchison,  to  the 
longer  duration  of  the  fever  and  to  the  greater  emaciation  which 
accompanies  it.  But  surely  the  chief  causes  are  the  unhealthy 
state  of  the  glandular  system,  which  often  predisposes  to  enteric 
fever,  and  is  certainly  intensified  by  it ;  and  the  infiltrated  condi- 
tion of  the  lung  tissue  in  this  fever.  This  is  apparently  the  view, 
taken  by  Liebermeister ,a  who  says — "  The  cases  under  considera- 
tion (of  general  miliary  tuberculosis)  occur  in  persons  who  have  the 
specific  poison  of  tubercular  phthisis  lying  latent  within  them,  and 
the  fever,  with  its  sequelae,  only  serves  as  an  exciting  cause  for  the 
development  of  these  processes."  Murchison  b  states  that  tubercle 
should  be  feared  when  hectic  fever  and  bronchitis  persist  after 
the  fourth  week,  and  Stokes  taught  that  a  quick  pulse-rate  in 
convalescence  indicated — (1)  tuberculosis  in  the  lungs  and  other 
parts ;  (2)  "  secondary  reactive  inflammation  in  the  mucous  glands 
of  the  intestines ; "  (3)  phlegmasia  dolens.  At  the  same  time  Stokes 
held  that  the  bronchial  affection  of  fever  often  simulated  phthisis, 
especially  in  those  cases  where  the  patient  lost  strength,  and  grew 
pallid  and  emaciated.*3 

5.  Laryngitis  is  a  serious  complication,  more  common  on  the 

Continent  than   in   Great  Britain   and   Ireland.     Ulceration   and, 

partial  destruction  of  the  epiglottis  appeared  to  Louis  to  be  such 

characteristic  secondary  anatomical  lesions  in  enteric  fever  that  he 

said — "  Si  on  venait  a  les  observer  chez  un  sujet  qui  aurait  suc- 

combe"  a  une  maladie  aigue,   elles  annonceraient  d'une  maniere 

presque  certaine,  et  sans  aller  plus  loin,  que  l'affection  est  une 

fievre  typho"ide."<J     These   laryngeal    ulcerations   are   at   present 

regarded   as   secondary  changes,   depending   on   a   circumscribed 

.  . 
a  Von  Ziemssen's  Cyclop,  of  the  Pract.  of  Med.     Vol.  I.,  page  173. 
fc  Lectures  on  Fever.     1874.     Pages  188,  189. 
c  Loc.  cit.     Page  135. 
d  Eecherches  sur  la  fievre  typholde.     Paris.     1841.     Page  321. 


ENTERIC   FEVER.  397 

"  diphtheritic "  infiltration  of  the  mucous  membrane.  They  are 
small,  but  may  extend  in  breadth  and  depth.  Sometimes  they 
become  confluent.  They  are  commonly  found  on  the  posterior 
wall  of  the  larynx,  and  may  engage  the  posterior  insertion  of  the 
vocal  cords.  They  may  also  involve  the  epiglottis,  especially  on 
its  lateral  edges,  when  they  cause  much  disturbance.  The  voice 
becomes  hoarse  and  rough,  there  may  be  severe  cough  and  difficulty 
of  swallowing  {dysphagia),  or  no  marked  symptoms  at  all  may  be 
present.  As  a  rule,  these  ulcerations  get  well  without  leaving  any 
untoward  after-effects ;  but,  on  the  other  hand,  they  may  lead  to 
death  by  producing  perichondritis  laryngea — the  perichondritis 
typhosa  of  Rokitansky — or  oedema  of  the  glottis. 

In  the  latter  case  life  is  occasionally  saved  by  tracheotomy.  In 
the  former  case,  should  the  patient  survive,  necrosis  and  exfoliation 
of  the  cartilages  of  the  larynx,  abscesses  in  the  neck,  and  permanent 
laryngeal  disease  may  result.  Of  all  these  accidents  Trousseau 
gives  a  full  account  in  his  lectures  on  Dothienenterie.a 

6.  General  Emphysema  and  Pneumothorax  may  result  from  a 
sloughing  ulcer  of  the  larynx,  or  from  ulceration  of  a  small 
bronchial  abscess,  or  a  gangrenous  cavity  in  the  lung.  Chomel.b 
Wilks,c  W.  T.  G-airdner,d  Beck,e  and  W.  Cayley,f  are  our  authorities 
on  this  subject. 

II.  The  Circulation. 

1 .  Degeneration  of  the  muscular  tissue  of  the  heart  exists  in 

-all  severe  cases  of  enteric  fever,  though  not  to  the  same  extent  as 

in  typhus.     Dr.  Hayem's  researches  on  the  changes  which  occur 

in  the  heart  in  enteric  fever  (Gaz.  Hebdom.  de  Med.,  1874,  Nos.  50 

51),  would  go  to  show  that  these  consist  not  only  in  a  granular  and 

fatty  infiltration  of  the  muscular  fibres,  but  also  in  inflammatory 

changes.     In   addition   to  the  signs  of  weakened-heart  given   by 

Dr.  Stokes,  a  careful  physical  examination  in  cases  of  developing 

*Cinique  Med.  de  VHdtel  Dieu.     Paris.     1865..  Tome  I.,  pages  274,  et  seq. 

b  Lecons  de  Clinique  Mid.     Paris.     1834.     Touie  I. 

c  Tram.  Path.  Soc.  Lond.     Vol.  IX.,  page  34.     1837. 

a  Gltisg.  Med.  Journ.     January,  1865. 

*Verhandl.  der  phys.-med.  Gesellsch.  in  Wilrzburg.     1868.     Pao-e  2. 

f  Trans.  Clin.  Soc.  Lond.     Vol.  XVI. 


398  ENTERIC   FEVER. 

heart-failure  will  show — (1)  an  enlarged  area  of  precordial  dulness 
on  percussion,  particularly  in  a  transverse  direction  across  the  chest 
and  towards  the  right  side  (over-filling  of  the  right  chambers) ; 
(2)  evidences  of  an  undue  mobility  of  the  heart — when  the  patient 
changes  his  position  from  side  to  side,  the  heart  "  sags  "  over,  now  to 
one  side,  now  to  the  other ;  and  (3)  failure  of  the  radial  pulse  when 
the  arm  is  held  aloft.  Coldness  of  the  lobe  of  the  ear  is  another 
sign  of  failing  heart  not  to  be  despised.  This  heart  degeneration 
leads  to  many  complications  in  different  parts  of  the  body — for 
example,  hemorrhagic  infarctions  in  the  lungs,  spleen,  or  kidneys, 
with  resulting  necrotic  or  gangrenous  processes,  bedsores  from  mal- 
nutrition, and  so  on. 

2.  Pericarditis  and  Endocarditis  are  rare.  The  former  lesion 
is  generally  latent,  but  its  physical  signs  reveal  its  presence. 

3.  Haemorrhages  from  the  nose  (epistaxis)  and  intestines  (melcena) 
are  not  uncommon ;  and  acute  haemophilia  is  occasionally  met  with, 
constituting  what  has  been  called  "  hemorrhagic  putrid  fever." 

4.  Venous  Thrombosis  is  more  common  in  enteric  fever  than  in 
typhus.  Arterial  Thrombosis,  leading  to  spontaneous  gangrene,  is 
very  rare,  even  less  so  than  in  typhus. 

5.  Pyaemia. — Murchison  has  occasionally  met  with  examples  of 
this  condition  during  convalescence. 

III.  The  Nervous  System. — Meningitis,  mental  fatuity,  and 
mania,  convulsions,  muscular  tremors  and  chorea  (Nothnagel), 
neuralgia  and  hyperesthesia  (Nothnagel),  are  occasionally  met  with. 
Paralysis  is  also  an  occasional  sequel.8. 

For  a  full  account  of  the  Nervous  Lesions  in  Enteric  Fever 
reference  may  be  made  to  a  monograph  by  H.  Nothnagel,  entitled : 
"  Die  nervosen  Nachkranheiten  des  Abdominaltyphus"  a 

Liebermeister  draws  attention  to  a  condition  of  special  interest, 
which  sometimes  develops  at  the  height  of  the  disease,  and  which 
he  calls  "  irritation  of  the  brain,  with  depression  of  temperature." 
He  has  seen  eight  or  ten  cases  in  which  head  symptoms,  suggestive 
of  meningitis,  or  well-marked  melancholic  or  maniacal  symptoms, 
with  insensibility  of  the  pupils  to  light,  set  in  about  the  middle  of 
a  Deutsches  Archiv.  fur  klin.  Median.     Band  IX.,  page  480.     1872. 


ENTERIC    FEVER.  399 

the  second  week.  These  symptoms  are  due,  in  Liebermeister's 
opinion,  to  irritation  of  the  brain  by  the  high  temperature ;  and 
the  fall  of  temperature — from  104°  to  between  97°  and  102°  as 
extreme  limits — which  accompanies  these  symptoms  he  attributes 
to  the  heat-regulating  centre  being  itself  involved  in  this  irritation.8- 

IV.  Organs  of  Special  Sense.—  Otorrhcea  not  infrequently 
occurs,  particularly  in  children.  When  the  internal  ear  is  involved, 
meningitis  may  result,  as  already  explained.  Deafness  may  follow 
enteric  fever.  Amaurosis  and  amblyopia  are  mentioned  as  sequels 
by  Nothnagel.     The  cornese  may  slough  from  atrophy. 

V.  Organs  of  Digestion. — 1.  Catarrhal  (Liebermeister)  or  diph- 
theritic (Murchison)  pharyngitis  may  cause  dysphagia,  which  may 
also  result  from  dryness  of  the  throat,  muscular  paralysis  in  severe 
cases,  or  as  a  purely  nervous  affection. 

2.  Vomiting  may  occur — (a)  at  the  beginning  of  the  fever;  (/?) 
in  the  middle  and  later  periods  from  overfeeding  or  in  connection 
with  peritonitis  ;  (<y)  in  convalescence,  when  it  is  often  a  nervous 
symptom,  according  to  Trousseau,b  and  is  best  treated  by  giving 
solid  food  : — "  Les  accidents  que  nous  signalons  ici  sont  des  acci- 
dents nerveux,  des  troubles  de  secretions ;  le  meilleur  moyen  de  les 
combattre,  est  d'insister  au  contraire  sur  une  alimentation  solide." 

3.  Diarrhoea,  from  an  atonic  state  of  the  intestinal  ulcers,  may 
exhaust  the  patient  after  the  fever  has  ceased. 

4.  Dysentery  has  often  been  known  to  co-exist  with  enteric 
fever  (Murchison,  Forget,  R.  D.  Lyons,  and  Gairdner). 

5.  Jaundice. — Murchison  met  with  three  cases,  in  all  of  which 
death  ensued,  the  liver  being  small  in  two  which  were  examined, 
and  its  secreting  cells  loaded  with  oil.  It  is  usually  a  fatal  com- 
plication, but  is  happily  rare. 

6.  Peritonitis,  next  to  perforation,  is  the  complication  of  enteric 
fever  which  is  most  to  be  dreaded.  Its  symptoms  are  : — Sudden 
collapse,  excruciating  pain,  great  tenderness  on  pressure,  vomiting 
and  diarrhoea.  The  pulse  is  quick  and  thready,  the  extremities 
are  cold,   and   the  face  wears  an    anxious,   pinched    appearance. 

a  hoc.  cit.     Page  178. 

b  Clinique  Med.  de  VHdtel  Dieu.     Paris.     1865.     Tome  I.,  p.  264. 


400  ENTERIC   FEVER. 

Sometimes  peritonitis  is  latent,  but  the  last  two  symptoms  will 
generally  reveal  its  presence  even  then. 

The  causes  of  this  dangerous  complication  are,  after  Murchison  — 
(1).  Perforation  of  the  intestine. 

(2).  Extension  of  inflammation  from  the  mucous  to  the  peri- 
toneal coat  of  the  intestine  without  perforation. 
(3).  Softening  and  rupture  of  infarctions  in  the  spleen. 
(4).  Bursting  into  the  peritoneum  of   a  softened   mesenteric 

gland. 
(5).  Bursting  into  the  peritoneum  of  an  abscess  in  the  wall  of 
the  urinary  bladder,  or  in  the  ovary,  or  in  the   sheath  of 
the  rectus  muscle. 
(6).  Ulceration  of  the  gall-bladder,  leading  to  perfoi'ation. 
"Where  peritonitis  results  from  extension  of  inflammation  from 
the  mucous  to  the  peritoneal  coat  of  the  intestine  without  perfora- 
tions, its  distribution  may  be  local,  not  general. 

7.  Perforation  of  the  bowel,  with  escape  of  its  contents  into  the 
peritoneum  is  the  deadliest  accident  which  can  occur  in  enteric 
fever,  It  occurred  in  3*04  per  cent,  of  1,580  cases  under  Mur- 
chison's  care,  in  2'3  per  cent,  of  600  cases  observed  by  Griesinger, 
and  in  2*74  per  cent,  of  73  cases  observed  by  Austin  Flint  in 
America.  From  these  figures  we  may  say  that  one  in  about  every 
33  enteric  fever  patients  dies  from  perforation — the  accident 
occurring  in  the  third,  fourth,  or  fifth  week,  and  much  more  com- 
monly in  men  than  in  women.  Indigestible  food,  distension  of  the 
ulcerated  bowel  with  gas  or  faeces,  vomiting,  and  movements  on 
the  part  of  the  patient,  are  the  usual  determining  causes  of  the 
catastrophe,  which  is  speedily  followed  by  death  in  most  instances. 
Evidence,  however,  is  forthcoming  to  show  that  recovery  does  in 
rare  cases  follow  perforation  of  the  bowel  in  enteric  fever. 

Hoelschera  studied  the  records  of  2,000  deaths  from  enteric 
fever  in  the  Munich  Hospital,  and  found  that  of  this  number  1 14 
deaths  were  caused  by  perforation.  Not  a  single  death  from  per- 
forative peritonitis  was  recorded  as  occurring  in  the  first  two 
weeks  of  the  disease. 
a  Munchener  med.  WochenscJi.     January,  1891.     Vol.  XXX VIII.,  page  43. 


ENTERIC    FEVER.  401 

Notes  of  43  cases  of  perforation  of  the  intestine  in  389  cases  of 
Continued  Fever — that  is,  in  11  per  cent.,  are  given  in  the  Post- 
mortem Records  of  the  Continued  Fevers,  contained  in  the  third 
medical  volume  of  the  "  Medical  and  Surgical  History  of  the  War 
of  the  Rebellion,"  prepared  under  the  direction  of  the  Surgeon- 
General  of  the  United  States  Army,  by  Charles  Smart,  Major  and 
Surgeon,  U.  S.  A.a  Of  these  cases  of  perforation  12  occurred  in  50 
cases  of  undoubted  enteric  fever — that  is,  in  24  per  cent.;  6,  in 
fil  cases  of  so-called  typho- malarial  fever,  or  in  9*8  per  cent.;  and 
24,  in  313  mixed  cases.  In  addition  to  these  42  cases,  there  was 
the  case  of  a  private,  aged  20,  who  succumbed  to  an  intercurrent 
attack  of  pneumonia. 

"  The  occurrence  of  perforation,"  writes  Murchison,  "  is  denoted 
by  the  sudden  supervention  of  collapse,  with  or  without  rigors,  but 
with  acute  pain  and  tenderness  of  the  abdomen,  which  at  the  same 
time  is  tense  and  tympanitic.  Vomiting  is  common,  and  often 
precedes  the  other  symptoms  for  several  days,  and  is  then  often 
accompanied  by  an  increase  of  diarrhoea,  with  or  without  intestinal 
haemorrhage.  The  decubitus  is  dorsal,  with  the  legs  drawn  up  ;  the 
temperature  rises ;  the  pulse  is  rapid,  thready,  or  imperceptible ; 
the  breathing  is  thoracic ;  the  countenance  pale,  pinched,  and 
expressive  of  suffering;  and  there  is  great  thirst,  and  ofien  sup- 
pression of  urine.  Soon  the  prostration  becomes  extreme,  the 
extremities  cold,  and  the  face  covered  with  large  drops  of  perspira- 
tion, and  the  patient  gradually  sinks,  the  mind  remaining  clear  to 
the  last."  & 

When  recovery  takes  place  after  perforation — as  it  does  in  rare 
instances— it  is  brought  about :  (1)  by  the  cessation  of  peristalsis ; 
(2)  by  pressure  of  the  surrounding  viscera ;  (3)  by  the  formation 
of  adhesions  ;  (4)  by  extrusion  of  mucous  membrane  so  as  to  close 
the  rent  in  the  peritoneum  ;  and  (5)  by  intrusion  of  a  portion  of 
omentum,  which  becomes  adherent  and  so  stops  the  rent. 

VI.  The  Urinary  Organs.— Nephritis  and  hematuria  are  serious 

a  Washington :  Government  Printing  Office.  1888.  Pages  334,  et  seq. 
Cf .  page  452,  loc  cit. 

b  Loc.  cit.     Pages  570,  571. 

2   D 


402  ENTERIC    FEVER. 

complications  of  enteric  fever,  and  vesical  catarrh  from  neglected 
retention  of  urine  sometimes  gives  trouble  in  convalescence. 

VII.  The  Female  Organs  of  Generation. — Profuse  menstrua- 
tion  may  complicate  enteric  fever.  Contrary  to  the  opinion  of 
Rokitansky  and  Niemeyer,  pregnancy  does  not  confer  immunity 
from  this  fever.  The  same  remark  applies  to  lactation.  Dr. 
J.  Marshall  Day,  the  Resident  Medical  Officer  of  Cork-street  Fever 
Hospital,  has  furnished  me  with  particulars  of  five  cases,  all  of  which 
have  come  under  notice  within  the  past  few  months,  illustrative  of 
this  statement.  A  young  woman,  aged  22,  was  admitted  on  the 
second  day  of  enteric  fever,  nursing  an  infant  five  weeks  old ; 
another  patient,  aged  25,  was  admitted  on  the  eighth  day,  nursing 
an  infant  of  three  months;  a  third  was  a  married  woman,  seven 
months  pregnant,  admitted  on  the  twenty-first  day,  who  did  not 
abort;  a  fourth  was  a  young  woman,  aged  26,  six  months  preg- 
nant, five  days  ill  on  admission,  who  did  not  abort ;  and  the  fifth 
was  a  married  woman,  ten  days  ill,  three  months  pregnant.  This 
patient  aborted,  but  made  a  good  recovery  from  fever.  Pregnancy 
is  a  less  serious  complication  than  was  formerly  supposed,  nor  does 
abortion  or  miscarriage  necessarily  take  place. 

VIII.  The  Tissues,  Integuments,  and  Bones  may  be  the  seat  of 
the  following  complications:  — 

1.  Erysipelas,  mostly  of  the  face,  appears  in  an  advanced  stage, 
is  sometimes  associated  with  otorrhoea,  and  is  often  fatal. 

2.  Anasarca. — Locally  from  venous  thrombosis  ;  general,  from 
weak  heart  in  convalescence.  Liebermeister  gives  several  reasons 
why  oedema  is  not  present  with  weak  heart  during  the  fever. 

3.  Bedsores  (gangrene  from  pressure)  are  more  common  in 
enteric  fever  than  in  typhus — extreme  emaciation,  long  duration, 
and  diarrhoea  being  the  cause  of  this. 

4.  Cancrum  oris,  or  Noma,  is  a  rare  complication  in  children. 
Murchison  met  with  only  one  instance.  Two  cases  are  mentioned 
by  Charles  West. 

5.  Ulceration  from  blisters  (Louis),  or  too  hot  poultices.  Of 
this  I  have  occasionally  seen  deplorable  examples — one  quite 
recently. 


ENTERIC    FEVER.  403 

6.  Necrosis  is  a  more  frequent  sequel  of  this  fever  than  of  typhus. 

7.  Periostitis  is  an  occasional  sequela,  to  which  Sir  James  Paget 
has  drawn  attention .a 

8.  Buboes. — Parotitis  is  an  infrequent,  but  serious  complication, 
Mnrehison  met  with  6  cases  of  parotid  bubo,  of  which  5  terminated 
fatally.  Trousseau  says  b  :  "  Ce  que  les  anciens  auraient  appele"  une 
crise  ou  une  me'tastase,  je  l'appelle  une  tr^s  funeste  complication." 
According  to  Hoffmann,  16  cases  of  suppurative  parotitis  were 
found  at  Basle  among  about  1.600  enteric  fever  patients,  7  of  the 
16  proving  fatal.  Liebermeister  considers  that  the  frequency  of 
suppurative  parotitis  has  greatly  diminished  since  the  introduction 
of  a  systematic  antipyretic  treatment. 

To  the  foregoing  complications  and  sequelae,  Murchison  adds 
Marasmus.  After  a  severe  attack,  the  patient  remains  weak  and 
anaemic,  and  progressively  emaciates.  His  appetite  may,  or  may 
not,  be  good.  His  digestion  is  bad,  and  he  suffers  from  flatu- 
lence, borborygmi,  or  rumbling  noises  in  the  abdomen,  and  occa- 
sional diarrhoea. 

In  fatal  cases  Murchison  found  the  intestinal  mucous  membrane 
abnormally  smooth,  and  the  mesenteric  glands  were  shrivelled.  In 
the  second  volume  of  the  British  Med.  Journal  for  1871,  page  547, 
an  interesting  paper  on  this  subject  by  Dr.  Clifford  Allbutt,  of 
Leeds,  will  be  found.  It  is  on  "  Marasmus  as  an  Occasional  Con- 
sequence of  Enteric  Fever." 

To  Murchison's  list  of  the  complications  of  enteric  fever,  Dr. 
Cayley  adds  "  Sudden  Death,"  sometimes  during  the  height  of  the 
attack,  but  much  more  frequently  at  the  commencement  of  con- 
valescence, at  the  end  of  the  third  or  in  the  fourth  week.  Various 
explanations  of  this  untoward  event  have  been  suggested,  such  as 
cardiac  softening,  thrombosis  or  embolism  of  the  pulmonary  artery, 
"  reflex  spasm"  (Dieulafoy),  ischeemia  of  the  brain,  pneumatosis  of 
the  blood,  mental  emotion  or  muscular  exertion.  Dr.  Cayley  gives 
two  illustrative  cases.  In  the  second  of  these  the  patient,  a  fat, 
flabby  woman  of  thirty-five,  died  suddenly  on  the  23rd  day  of  a 

a  Barth.  ITosp.  Reports.     1877. 
b  Trousseau.     Loc.  cit.     P.  246. 


404  ENTERIC   FEVEE. 

mild  enteric  fever.  In  the  morning  she  seemed  to  be  going  on 
well,  and  expressed  a  wish  for  food ;  at  4  50  p.m.  she  suddenly 
cried  out  that  she  was  in  great  pain,  and  fell  back  dead.  An  in- 
complete record  of  the  post-mortem  appearances  informs  us  that 
there  was  a  firm  laminated  clot  in  the  right  ventricle,  extending 
into  the  pulmonary  artery;  but  the  intense  pain,  expressed  by  an 
articulate  cry,  points  to  perforation  as  the  proximate  cause  of  death. 
And  this  presumption  is  strengthened  on  the  supposition  that  her 
"wish  for  food" — i.e.,  solid  food,  had  been  gratified. 

Co-existence  of  other  Specific  Diseases  with  Enteric  Fever. — 
Scarlatina,  measles,  variola,  vaccina,  pertussis  or  whooping- 
cough,  diphtheria,  erysipelas,  and  especially  typhus,  may  all  co- 
exist with  typhus — notwithstanding  John  Hunter's  dogma  to  the 
contrary .a  Murchison  had  notes  of  8  cases  in  which  the  eruptions 
of  enteric  fever  and  of  scarlatina  co-existed.  Dr.  A.  P.  Stewart 
saw  a  case  at  the  Middlesex  Hospital  of  the  co-existence  of  small- 
pox, vaccina,  and  enteric  fever.  I  believe  that,  in  former  days, 
when  the  essential  difference  between  typhus  and  typhoid  had  not 
yet  come  to  be  recognised,  it  may  even  have  been  the  rule  for  these 
two  fevers  to  run  their  course  concurrently — the  enteric  fever  cases 
contracting  typhus  in  the  wards  in  which,  they  were  placed  for 
treatment. 

As  a  typical  and  classical  example  of  the  co-existence  of  typhus 
and  enteric  fever,  I  would  instance  a  case  presented  in  admirable 
detail  by  Dr.  Christopher  J.  Nixon,b  Physician  to  the  Mater  Miseri- 
cordise  Hospital,  Dublin,  to  the  Medical  Section  of  the  Eoyal 
Academy  of  Medicine  in  Ireland,  in  December,  1888.  The  patient 
died,  and  the  intestinal  lesions  of  enteric  fever  were  proved  to  be 
present,  while  the  typhus  rash  had  been  observed  from  the  fifth  day 
of  the  disease,  death  occurring  on  the  twelfth  day.  In  the  discusr 
siori  which  followed  the  reading  of  Dr.  Nixon's  paper  several 
analogous  cases  were  mentioned— -one  of  these  had  occurred  in  my 
own  practice  shortly  before.0  : 

.     aSeepage28,  --- 

b  Trans.  Royal  Academy  of  Med.  in  Ireland.  Vol.  VII.,  page  22.  1889.  And 
Dubl,  Journ.  of  Med.  Science.     Vol.  LXXXVIIL,  page  97.     Au/ust,  Ia89. 

aDubl.  Journ.  of  Med.- Science.  •  Vol.  LXXXVIL.,  page  248.     March,  1889. 


405 


CHAPTER    XLI. 
Varieties  of  Enteric  Fever. 

"  Typho-malarial  Fkver  "—Varieties  of  Enteric  Fever  :  Abortive  form 
(fidvre  muqueuse),  latent  form  {Typhus  ambulatorius),  "gastric,"  or  "  bilious  fever, " 
spleno-tvphoid,  acute  or  inflammatory  form,  infantile  remittent  fever  ("  worm 
fever,"  or  "gastric  fever"),  senile  enteric  fever,  afebrile  or  apyrexial  form. 

Many  varieties  of  Enteric  Fever  have  been  described  by  syste- 
matic writers — for  example  :  The  adynamic  or  low  nervous  form,  the 
ataxic  form,  the  abdominal  form,  the  thoracic  form,  tbe  hemorrhagic 
form,  and  the  ague-like  form.  This  last  is  seen  chiefly  in  persona 
who  have  been  exposed  to  malarial  poisoning,  and  in  whom  the 
poisons  of  the  two  diseases  may  be  supposed  to  co-exist.  This 
form  received  the  name  of  Typho-malarial  Fever  from  Dr.  Wood- 
ward, and  the  Royal  College  of  Physicians  of  London,  following 
the  opinion  expressed  at  the  International  Medical  Congress  at 
Philadelphia  in  1876,  places  the  name  as  a  sub-division  of  enteric 
fever,  and  describes  the  disease  as  a  combination  of  malarial  and 
enteric  fevers,  as,  in  other  words,  a  compound  fever  resulting  from 
the  simultaneous  action  of  two  distinct  poisons.  In  the  Lancet  for 
1887,  Dr.  J.  Edward  Squire  protested  against  these  views,  and  used 
the  term  "  typho-malarial "  to  designate  a  malarial  fever  which 
assumed  an  adynamic  type,  such  as  is  presented  in  enteric  fever — 
the  form  he  had  observed  among  the  troops  around  Suakim  during 
the  campaign  of  1886. 

The  correct  view,  no  doubt,  is  that  "typho-malarial  fever"  is 
really  enteric  fever  showing  itself  in  an  individual  already  the 
victim  of  malarial  poisoning,  perhaps  months  or  years  before.  It  is 
surely  a  matter  of  every-day  clinical  experience  that  malaria  asserts 
its  presence  whenever  its  victim  falls  sick  of  an  acute  disease. 

The  varieties  of  enteric  fever  which  call  for  especial  notice  are 
the  following  : — 

1.  The  abortive  form,  in  which  the  fever  does  not  run  its  regular 
course,    the    intestinal    lesions    undergoing    resolution    instead    of 


406  ENTERIC    FEVER. 

advancing  to  ulceration.  This  is  the  fievre  muqueuse  of  French 
writers.  The  attack  begins  like  one  of  ordinary  enteric  fever,  but 
about  the  10th  or  12th  day  an  improvement  is  observed,  and  the 
fever  dies  out  in  the  early  part  of  the  third  week. 

2.  A  more  dangerous,  because  more  insidious,  variety  is  that  to 
which  the  name  latent  enteric  fever  is  applied.  It  was  described 
by  Dr.  Hewett,  of  London,  in  1826,  and  also  by  Louis,  Chomel, 
and  other  writers.  A  patient  is  feverish  and  complains  of  lassitude 
and  weakness,  or  is  thought  merely  to  be  suffering  from  a  "  feverish 
cold,"  or  from  a  "  bilious  attack "  or  a  "  gastric  fever."  His  illness 
is  sometimes  spoken  of  as  "  simple  continued  fever."  Suddenly, 
under  such  circumstances,  he  becomes  delirious  or  maniacal,  or 
profuse  intestinal  haemorrhage  sets  in,  or  symptoms  of  perforation 
appear  and  the  patient  dies.  Cases  of  this  kind  are  called  in 
Germany  "  Typhus  ambulatorius,"  because  the  victim  may  pass 
through  his  illness  on  his  feet,  until  the  final  catastrophe  comes. 

3.  The  so-called  "  Gastric"  or  "Bilious  Fever"  is  really  enteric 
fever  in  a  rudimentary  or  aberrant  form.  Of  this  kind  was  one 
of  the  series  of  four  cases  of  illness  due  to  the  use  of  impure  drink- 
ing water  in  a  Training  College  in  Dublin,  which  came  under  my 
notice  some  years  ago,  and  to  which  I  have  already  referred  (see 
page  361). 

4.  Contrasted  with  the  last-named  variety,  is  the  so-called 
"  Spleno-typhoid."  At  the  Tenth  International  Medical  Congress 
at  Berlin  in  1*90,  Eiselt,a  of  Prague,  made  a  communication  on 
what  he  described  as  "  Die  lienale  Form  des  Ileotyphus" — "the 
splenic  form  of  Enteric  Fever,"  in  which  the  spleen  bears  the  brunt 
of  the  infection  while  intestinal  complications  are  wanting.  The 
spleen  is  voluminous,  but  spirilla  are  not  found  in  the  blood,  and 
that  the  cases  are  really  examples  of  enteric  fever  is  demonstrated 
by  the  origin  of  the  attack  and  by  intestinal  ulceration  found  in 
fatal  cases. 

In  the  Proceedings  of  the  Pathological  Society  of  Dublin  for  1882 
(Vol.  IX.,  New  Series,  page  26),  will  be  found  an  account  of  a  case 

*  Verhandlunyen  des  X.  Inter, >at.  Med.  Congresses.  Berlin.  Band  II.  Abthei- 
lung  V.     Innere  Medicin.      210. 


ENTERTC    FEVER  407 

of  Spleno-typhoid  which  occurred  in  my  practice  in  the  autumn  of 
1880.     Further  allusion  will  be  made  to  this  case  at  page  422. 

5.  In  certain  instances  the  fever  is  very  acute,  and  death  may 
occur  in  the  first,  or  early  in  the  second  week,  before  ulceration  has 
commenced  in  the  bowel.  Trousseau  a  describes  this  variety  as  la 
forme  inflammatoire,  and  Murchison  gives  several  examples  of  it 
in  his  work  on  Fevers.  Some  years  ago  I  witnessed  a  case  of  this 
kind  in  the  Epidemic  Wards  of  the  Meath  Hospital. 

6.  Infantile  Remittent  Fever,  often  called  "  Worm  Fever "  or 
"  Gastric  Fever,"  is  now  known  to  be  identical  with  the  enteric 
fever  of  adults.  According  to  Murchison's  experience,  idiopathic 
remittent  fever  in  children  is  almost  invariably  enteric.  An  excel- 
lent account  of  the  fever  will  be  found  in  Dr.  Charles  West's  work 
on  the  "  Diseases  of  Infancy  and  Childhood." b  It  is  to  this 
author  that  we  are  principally  indebted  for  establishing  the  identity 
of  infantile  remittent  and  enteric  fever. 

7.  Senile  Enteric  Fever  may  be  veiled  or  latent.  The  abdominal 
symptoms  are  often  but  slightly  marked,  and  temperature  does  not 
range  high.  The  fever,  however,  is  protracted  and  collapse  is  not 
uncommon.  Hilton  Fagge  suggests  that  the  atrophy  of  the  lym- 
phatic organs  in  old  age,  including  those  of  the  ileum,  may  be  an 
anatomical  condition  which  is  unfavourable  to  the  reception  and 
multiplication  of  the  enteric  microbe.  The  same  line  of  thought 
would  explain  the  special  features  of  the  disease  as  it  presents  itself 
in  elderly  patients. 

8.  The  afebrile  or  apyrexial  form  is  of  rare  occurrence.  Although 
the  general  symptoms,  and  especially  the  nervous  symptoms,  as 
delirium  and  stupor,  may  be  well  marked  and  rose-spots  are  present, 
yet  the  temperature  remains  normal  throughout,  or  may  even  be 
subnormal.  The  intestinal  lesions  are  usually  slight,  and  the 
disease  often  terminates  at  the  end  of  a  fortnight.  An  outbreak  of 
this  type  occurred  in  the  German  army  besieging  Paris  in  the 
winter  of  1870-71,  and  has  already  been  mentioned  at  page  395. 

*■  Clinique  Med.de  VH6tel  Dieu.     Paris.     1865.     Tome  I.,  p.  241. 
b  London  :  Longmans,  Green  &  Co.     1874.     Sixth  Edition.     Pages  769,  et 
eeq. 


408 


CHAPTER  XLII. 

Enteric  Fever  (continued). 

Dia  gnosis — Prognosis  and  Mortality— Pathology. 

No  single  symptom  pathognomonic  of  Enteric  Fever. — Diagnosis  depends 
on  aetiology,  course  of  the  disease,  and  particularly  the  temperature. — 
Ehrlich's  Test.  Diseases  apt  to  be  confounded  with  Enteric  Fever  : 
Typhus,  relapsing  fever,  remittent  fever,  scarlatina,  smallpox,  pyaemia  and 
puerperal  fever,  gastro-intestinal  form  of  influenza,  tuberculosis,  trichiniasis, 
ulcerative  endocarditis,  acute  rheumatism,  &c.  Prognosis  and  Mortality  : 
Influence  of  age,  sex,  season,  station  in  life,  recent  residence  in  an  infected 
locality,  intensity  of  the  poison,  family  constitution,'  personal  constitution 
and  habits,  previous  diseases. — Modes  of  Death  :  Coma,  syncope,  asthenia 
or  anaemia,  hyperpyrexia  (rarely). — Fatal  Complications. — Pathological 
Anatomy  :  Specific  Lesions — Non -Specific  Lesions  :  affecting  muscles,  heart, 
liver,  kidneys,  nerve-cells,  salivary  glands,  pancreas,  larynx. 

"  There  is  not  a  single  symptom  belonging  to  typhoid  fever  which 
can  be  characterised  as  pathognomonic."  So  writes  Liebermeister. 
Yet  the  diagnosis  is  tolerably  certain  in  most  cases,  and  absolutely 
so  in  well-marked  cases. 

Due  consideration  having  been  paid  to  the  circumstances  under 
which  the  illness  arose,  to  the  age  and  condition  of  the  patient  as 
regards  pregnancy  and  so  on,  the  diagnosis  turns  upon  the  course  of 
the  disease,  particularly  as  regards  the  behaviour  of  the  tempera- 
ture, upon  the  enlargement  of  the  spleen  and  the  abdominal 
symptoms,  and  upon  the  presence  of  the  rose-spots. 

Probably  it  is  to  the  temperature  that  we  are  to  look  with  most 
confidence  for  a  diagnosis  in  the  early  days  of  the  fever. 

Wunderlich  considers  that  one  is  justified  in  positively  diagnos- 
ticating enteric  fever  in  attacks  of  moderate  severity  during  the 
fastigium,  when  previously  healthy  persons  of  youthful  or  middle 
age,  after  being  ill  about  five  days  or  a  week,  exhibit  evening 
temperatures  of  103'5°  to  105°,  alternating  with  morning 
temperatures  which  are  1*4°  to  2'7°  Fahr.  lower.  He  qualifies 
this  statement  by  adding  : — "  Unless  some  other  disorder  of  any 


ENTERIC    FEVER.  409 

sort  can  be  discovered  to  explain  the  height  of  the  fever,  or  unless 
they  have  been  the  subjects  of  gross  neglect  immediately  before 
coming  under  observation." 

Wunderlich  further  thinks  that  we  may  with  great  probability 
assume  that  enteric  fever  is  not  present,  when  even  on  the  first  day 
or  on  the  second  morning  the  temperature  rises  to  104°  F. ;  when, 
between  the  4th  and  6th  days,  the  evening  temperature  in  a  child, 
or  adult  under  middle  age,  never  reaches  103°  F.,  and  indeed  if  it 
has  failed  to  do  so  two  or  three  times  ;  lastly,  when  as  early  as  the 
second  half  of  the  first  week  considerable  or  progressive  diminu- 
tions of  the  evening  temperature  are  met  with. 

Ehrlich's  Test. — In  1882,  Ehrlicha  announced  the  fact  that  it  is 
characteristic  of  the  urine  in  enteric  fever,  measles,  and  acute  tuber- 
culosis to  yield  a  deep-red  colour  with  diazo-benzene-sulphonic 
acid— one  of  the  anilin  derivatives — whereas  normal  urine  gives 
only  a-  yellowish  colour  (like  sherry  or  brown  vinegar)  with  this 
reagent.  Ehrlich  obtains  the  reaction,  not  with  the  acid  in  ques- 
tion itself,  but  with  sulphanilic  acid.  In  applying  the  test  two 
solutions  are  used — A,  a  saturated  solution  of  sulphanilic  acid  in 
dilute  hydrochloric  acid  (1  in  20)  ;  _B,  a  0*5  per  cent,  solution  of 
sodic  nitrite  in  distilled  water.  A  is  prepared  by  making  up  50 
cubic  centimetres  of  hydrochloric  acid  to  100U  cc.  with  water  and 
adding  sulphanilic  acid  to  saturation.  To  200  cc.  of  this  mixture 
5  cc.  of  a  ^  per  cent,  solution  of  sodium  nitrite  are  added.  The 
action  of  hydrochloric  acid  upon  the  nitrite  of  sodium  forms  nitrous 
acid,  which,  in  the  presence  of  sulphanilic  acid,  is  converted  into 
diazo-benzene-sulphonic  acid.  This  is  added  to  the  urine  in  equal 
parts.  Ehrlich  has  recently  P  recommended  that  5  to  6  times  the 
volume  of  absolute  alcohol  should  be  added  to  the  fluid  to  be  tested, 
and  the  reagent,  prepared  as  above,  should  be  added  drop  by  drop 
to  the  filtrate.  The  urine  thus  treated  should  be  rendered  alkaline 
with  strong  ammonia.  When  the  test  is  applied  to  the  urine  of  a 
patient  with  enteric  fever,  the  colour  rapidly  turns  red,  the  tint 
varying  from  the  yellowish-red  of  bichromate  of  potassium  solution 

«  Zeitscb.  fur  klin.  Med.  V.  285.     1882. 
b  Cl.arite-Anualen.  XI.  139.     1886. 


410  ENTERIC   EEVER. 

through  ruby-red  to  the  colour  of  port  wine.  On  shaking  the  test 
tube  a  froth  is  produced,  which  usually  assumes  a  delicate  and  very 
characteristic  pink  colour. 

Dr.  Frederick  Howard  Taylor,a  of  the  London  Hospital,  has 
recently  (1889)  submitted  this  diagnostic  sign  of  enteric  fever  to  a 
careful  trial  at  that  hospital.  He  finds  that  the  reaction  is  not 
always  given  until  the  latter  part  of  the  first  week,  but  in  every  case 
it  is  forthcoming  during  a  great  part  of  the  febrile  period.  It  is 
this  fact  which  constitutes  the  great  value  of  the  test.  Unfor- 
tunately, however,  in  exceptional  cases,  the  reaction  is  given  in  other 
diseases.     Herein  lies  the  weakness  of  the  test. 

Dr.  Taylor  arrives  at  the  following  conclusions  : — 

1.  The  absence  of  the  reaction  is  practically  proof  positive  that 
the  case  in  question  is  not  one  of  enteric  fever  (provided  that  the 
disease  has  lasted  six  days  or  more,  and  that  the  temperature  has 
not  yet  fallen  to  normal). 

2.  Its  presence  suggests,  but  does  not  prove,  that  the  case  is  one 
of  typhoid — the  probability  being  greater  the  deeper  the  tint  pro- 
duced. 

3.  As  the  other  diseases  in  which  it  occurs  least  seldom  are  not 
those  which  most  closely  resemble  typhoid,  but  the  reverse — for 
example,  measles  and  phthisis  pulmonalis — the  significance  of  these 
exceptions  is  very  much  lessened. 

On  November  5th  and  6th,  1891,  I  had  the  advantage,  through 
the  kindness  of  Professor  Emerson  Reynolds,  and  with  the  aid  of 
Mr.  Emil  Werner,  of  testing  the  diagnostic  efficacy  of  this  very 
striking  test  in  a  series  of  specimens  of  urine.  Two  of  the  series  were 
non-typhoid  urines,  two  others  were  from  enteric  fever  patients,  and 
the  fifth  was  the  urine  of  a  gentleman,  aged  29,  on  the  13th  day  of 
well-marked  enteric  fever,  he  having  suffered  from  equally  well- 
marked  enteric  fever  14^  years  previously,  when  a  lad  of  15  years. 
In  all  cases  a  change  of  colour  in  the  urine  was  observed  on  applica- 
tion of  the  test.  In  the  non-typhoid  urines  only  a  deeper  yellow  was 
produced ;  in  the  undoubted  primary  typhoid  urines  a  beautiful  rose 
coloration  developed.  In  the  case  of  recurrence,  changes  interme- 
a  Lancet,  May  4,  1889. 


Plate  IX. 

CHARTS  OF  TEMPERATURE  RANGES  IN 
RECURRENT   ENTERIC  FEVER. 


J?f'^'T^i'Cs^f:^vc.Jc,.e^:pH^: 1,<j7/-  P^*^  <*y-d  15 r&»v- 


IfyZ.  -Seczwd-Afiadc,  0rfobe/;Mr^&;;89ll,a3e7ita$edJ#years. 


ENTERIC    FEVER.  411 

diate  between  these  extremes  were  noticed — it  whs  as  if  the  previous 
attack  exerted  some  controlling  influence  over  the  reaction. 

The  diseases  which  are  apt  to  be  confounded  with  enteric  fever 
are  the  following : — 

1.  Typhus. — Especially  because  this  fever  may  sometimes  be 
attended  with  diarrhoea,  just  as  enteric  fever  may  be  attended  with 
constipation.  But  enteric  fever,  in  contrast  to  typhus,  is  a  disease  of 
youth,  begins  insidiously,  is  usually  accompanied  by  diarrhoea,  lasts 
at  leasts  ten  days  longer  (24  as  compared  with  14  days),  terminates 
by  lysis,has  an  unchangeable  eruption,  which  never  becomes  petechial 
and  which  fades  after  death ;  is  characterised  in  general  by  a  clear 
complexion,  bright  eyes,  dilated  pupils,  persistent  headache  which 
sets  in  late,  arid  comparatively  moderate  prostration  ;  tenderness  of 
the  abdomen,  tympanites,  gargouillement ;  in  enteric  fever,  epistaxis 
is  common,  and  the  pathological  changes  are  specific,  being  found 
chiefly  in  the  ileum,  and  about  the  ileo-csecal  valve. 

2.  Relapsing  Fever. — But  the  aetiology,  the  sudden  rise  of  tem- 
perature in  this  disease,  the  persistent  pyrexia,  the  rapid  defer- 
vescence and  profuse  sweating,  the  absence  of  rose-spots,  diarrhoea, 
&c,  and  the  characteristic  relapse — are  all  points  of  contrast  too 
marked  to  be  mistaken  or  ignored. 

3.  Remittent  Fever. — In  countries  where  both  this  disease  and 
enteric  fever  prevail,  the  diagnosis  may  be  a  matter  of  great  diffi- 
culty. Murchison  thinks  that  the  eruption  is,  perhaps,  the  only 
distinctive  mark  of  enteric  fever  to  be  relied  on  ;  but  we  have  now 
in  addition  Ehrlich's  test  to  help  us  to  a  definite  conclusion. 

4.  Scarlatina. — An  accidental  prodromal  rash  in  enteric  fever 
may  simulate  this  disease ;  but  the  mode  of  onset  and  the  absence 
of  sore  throat  should  guide  us  to  a  right  conclusion.  In  a  child  the 
lobster-like  redness  of  the  surface  after  a  warm  bath  may  lead  to 
a  temporary  error  in  diagnosis. 

5.  Smallpox. — But  the  pain  in  the  back,  so  characteristic  of 
smallpox,  is  wanting  in  enteric  fever,  and  the  rose-spots  of  this 
latter  disease  appear  late  and  are  soft  and  velvety,  deleble  on  pres- 
sure, and  never  hard,  shotty  and  acuminated  as  in  smallpox. 

6.  Pysemia  and  Puerperal  Fever  may  both  resemble  typhoid. 


412  ENTERIC   FEVER. 

But  rose-spots  are  absent,  while  an  icteroid  tinge,  rigors,  and  pro- 
fuse sweatings  are  commonly  present.  The  ranges  of  temperature 
in  pyaemia  also  are  extremely  great. 

7.  The  gastro-intestinal  form  of  Influenza  may  simulate  enteric 
fever  ;  but  the  course  of  the  two  diseases  is  quite  different,  as 
will  appear  from  the  annexed  clinical  record,  which  I  included  in 
my  account  of  the  influenza  epidemic  of  1889-90,  as  observed  in 
Dublin  a: — 

"  On  Wednesday,  January  8,  1890,  Mr.  W.  B.S.  enjoyed  a  day's 
shooting  in  the  Co.  Wicklow.  The  following  day  he  returned  to 
town  in  his  usual  good  health;  but  in  the  afternoon  felt  chilly, 
complained  of  headache  and  nausea,  and  felt  utterly  miserable. 
He  went  to  bed  early,  but  passed  a  wretched  night— restless  and 
sleepless.  Next  morning  I  found  him  complaining  of  pains  in  the 
eyeballs,  back  of  the  head,  and  small  of  the  back.  Pulse  84;  tem- 
perature, 99*9°;  tongue  thickly  coated ;  complete  loss  of  appetite 
and  nausea.  He  felt  entirely  prostrate,  and,  at  my  evening  visit, 
expressed  his  belief  that  some  fish  which  he  had  eaten  for  dinner 
had  thoroughly  disagreed  with  him.  Two  miserable  days  of  sick- 
ness followed,  the  temperature  rising  on  the  morning  of  the  5th 
day  to  103*1°.  A  short  cough  had  set  in,  and  the  eyes  were  suf- 
fused and  tender.  There  was  constipation,  and  he  complained  of 
weight  and  fulness  in  the  pit  of  the  stomach.  Dr.  James  Little 
saw  him  with  me  and  thought  it  likely  that  the  fever  would  run  on 
for  some  time.  A  quiet  day  gave  promise  of  a  restful  night,  and 
this  promise  was  abundantly  fulfilled.  He  had  an  excellent  night, 
partly  due  to  20  grains  of  antipyrin,  with  20  minims  of  tincture  of 
gelsemium  in  a  draught  in  divided  doses  at  bedtime.  Next  morn- 
ing, pulse  76;  temperature  98*7°,  rising  to  100*2°  in  the  evening, 
but  without  any  return  of  restlessness.  Subnormal  temperatures 
followed  for  a  few  days — 96*4°  being  one  observation.  The 
tongue  cleaned  very  slowly,  and  several  days  of  extreme  languor 
and  weakness  preceded  final  convalescence.  This  gentleman's  wife 
had,  a  few  days  previously,  suffered  from  influenza,  from  which 
she  was  recovering  when  he  fell  ill.     She  nursed  him  and  got  a 

a  Dubl.  Joum.of  Med.  Science.    Vol.  LXXXIX.,  page  300.    April,  1890. 


ENTERIC    FEVER.  413 

relapse,  accompanied  with  cough,  bronchial  catarrh  and  absolute 
loss  of  appetite." 

8.  "The  various  manifestations  of  Tuberculosis,"  writes  Mur- 
chison,  "  constitute  the  maladies  most  difficult  to  distinguish  from 
enteric  fever."  He  instances  tubercular  meningitis,  tubercular 
peritonitis,  acute  tuberculosis  of  the  lungs,  and  latent  tubercle.  He 
mentions  a  distinctive  mark  of  tubercular  meningitis  which  he 
learned  by  letter  from  Dr.  Zuelzer,  of  Berlin.  On  ophthalmoscopic 
examination  Cohnheim  detected  minute  tubercles  in  the  chorioid  in 
a  large  number  of  cases  of  acute  tuberculosis.  In  enteric  fever, 
further,  as  pointed  out  by  Sir  William  Jenner,  headache  ceases 
before  delirium  begins — both  symptoms  run  concurrently  in  tuber- 
cular meningitis.  The  abdomen,  too,  is  often  retracted  (scaphoid) 
in  tubercular  meningitis,  and  the  tache  cerebrate  is  easily  produced. 

In  tubercular  peritonitis,  again,  the  temperature  generally  becomes 
sub-normal  after  a  time. 

As  to  pulmonary  tuberculosis,  we  now  possess  an  important  aid 
to  diagnosis  in  the  microscopical  examination  of  the  sputum,  in 
which  tubercle  bacilli  may  generally  be  found  in  abundance.  The 
most  convenient  test  to  employ  is  the  carbol-fuchsin  (Ziehl-Neelsen) 
fluid,  modified  by  Giinther.  Ten  cc.  of  a  concentrated  alcoholic 
solution  of  fuchsin  are  added  to  90  cc.  of  a  5  per  cent,  solution  of 
carbolic  acid.  The  specimen  of  sputum  is  immersed  in  a  watch- 
glassful  of  this  fluid,  which  is  then  warmed.  When  thus  fuchsin- 
coloured,  the  specimen  is  placed  in  a  watchglassful  of  a  solution 
consisting  of  100  grammes  of  a  25  per  cent,  sulphuric  acid  con- 
taining 2  grammes  of  methylene  blue.  The  preparation  is  then 
washed  in  water  and  mounted  in  Canada  balsam.  The  bacilli 
appear  red,  all  other  fungi  and  cells  blue. 

9.  Trichiniasis  gives  rise  to  pyrexia,  with  vomiting  and  diarrhoea, 
followed  by  ataxic,  or  typhoid,  symptoms  ;  and  thus  it  may  simulate 
enteric  fever.  The  diagnosis  turns  on  the  presence  of  severe 
muscular  pains,  oedema  of  the  eyelids,  and  sometimes  of  the  whole 
body ;  the  absence  of  rose-spots,  of  enlargement  of  the  spleen, 
and  of  epistaxis  (Murchison). 

10.  Ulcerative  (septic)  endocarditis  has  often  been  mistaken  for 


414  ENTERIC   FEVER. 

enteric  fever.  The  discovery  of  a  cardiac  murmur  should  in  most 
cases  suffice  to  prevent  this  error,  and  the  occurrence  of  haematuria 
or  hemiplegia,  while  not  decisive,  would  aid  the  diagnosis  (Hilton 
Fagge). 

1 1 .  Acute  Rheumatism. — The  occasional  association  of  enteric 
fever  with  symptoms  of  acute  rheumatism  is  alluded  to  by  Dr. 
Cayley,a  who  quotes  a  case,  reported  by  Dr.  Finlay  to  the  Clinical 
Society  of  London,  in  which  the  primary  attack  presented  the 
symptoms  of  acute  rheumatism;  a  relapse  occurred  after  14  days 
with  all  the  characters  of  enteric  fever,  and  on  the  10th  day  of  the 
new  attack  perforation  caused  death.  On  post-mortem  examination, 
besides  a  recent  slough,  some  ulcers  in  the  process  of  healing  were 
found  in  the  ileum,  showing  that  the  first  attack  had  been  accom- 
panied by  ulceration  of  Peyer's  patches.  As  to  the  essential  nature 
of  this  illness,  for  our  part  we  are  content  to  adopt  Murchison's 
words.  He  says : — "  In  several  instances  I  have  known  the  pains 
in  the  limbs  (in  enteric  fever)  assume  a  neuralgic  character,  and 
prevent  sleep ;  while  in  others  they  are  articular,  and  the  case  at 
first  simulates  rheumatism." 

Other  morbid  conditions  which  have  occasionally  led  to  doubt  or 
confusion  are: — Mania,  pneumonia,  gastro-enteritis,  a  "bilious 
attack"  (all  mentioned  by  Murchison);  acute  diffused  diphthe- 
ritic colitis,  typhlitis,  perinephritic  abscess,  abscess  of  the  liver, 
secondary  to  ulcerative  colitis  or  to  suppuration  in  the  broad 
ligament  of  the  uterus,  diphtheritic  inflammation  of  the  labia  (all 
mentioned  by  Hilton  Fagge  and  Pye-Smith)  ;  and  extravasation  of 
urine,  leading  to  stupor,  muttering  delirium,  and  a  dry  brown 
tongue  (Sir  William  Gull). 

Prognosis  and  Mortality. — "  The  forecast  in  enterica,"  says  Dr. 
Hilton  Fagge,b  "  depends  partly  upon  the  condition  of  the  patient 
before  its  invasion,  partly  upon  the  symptoms  which  gradually 
develop  themselves  as  each  case  goes  on,  and  partly  on  early  and 
judicious  treatment." 

a  Murchison  on  Continued  Fevers.     Third  Edition.     1884.     Page  535. 
h  Textbook  of  the  Principles  and  Practice  of  Medicine.     Third  Edition.    1891. 
Vol.- 1.,  page  168. 


100 


^   o?     55:§5^     &     <n    ^     ^     ^     ^     ^     <o    *>     ^     « 


1'  |   I  "I  I  4  i  §  I  1  8  a -s  « 


Diagram>D  shorn  the  vanolwns,  according  to  Age,  in  the  rate  of  Mori/My  of 5911  cases 
of  Enteric  Fever,  admitted  into  the  London,  Fever  Hospital,  (  Compare  wcthDiagr:  B- 
Only  47  of  patients  were  above  55  years) 


ENTERIC   FEVER.  415 

At  the  London  Fever  Hospital,  in  twenty-three  years  (1848- 
1870),  out  of  5,988  cases,  1,034  died,  making  a  death-rate  of  17*26 
per  cent.,  or  of  1  in  5*79.  The  mortality,  in  fact,  was  about  the 
same  as  that  of  typhus.  In  the  same  hospital,  in  the  years  1871-82, 
since  the  exclusion  of  the  pauper  patients,  144  deaths  occurred 
among  905  patients,  the  death-rate  being  15*9  per  cent.  (Wm. 
Cayley). 

The  statistics  which  I  have  culled  from  the  Registers  of  Cork- 
street  Fever  Hospital,  Dublin,  with  the  aid  of  Dr.  J.  Marshall  Day, 
the  Resident  Medical  Officer,  compare  very  favourably  with  these 
results.  In  the  twenty  years  ending  March  31,  1891  (1871-1890 
inclusive),  1,405  cases  of  enteric  fever  were  treated  in  the  hospital, 
of  which  121  proved  fatal.  These  figures  give  a  death-rate  of  1  in 
11-6  or  8 '6  per  cent. — only  one-half  the  mortality  in  the  London 
Fever  Hospital  up  to  1870. 

The  influence  of  age  on  the  mortality  is  shown  in  Diagram  D., 
copied  by  permission  from  the  Third  Edition  of  Murchison's  work. 
It  will  be  seen  that  the  rate  of  mortality  is  much  more  uniform 
at  all  ages  than  it  is  in  typhus.  At  Guy's  Hospital  the  mortality 
under  5  years  of  age  was  1  in  7,  or  14-3  per  cent. ;  between  5  and  15 
years,  it  was  rather  less  than  12  per  cent. ;  between  15  and  30,  it 
was  a  little  more  than  16  per  cent.;  between  30  and  40  a  little 
more  than  26  per  cent.,  and  above  40  nearly  50  per  cent.  (Hilton 
Fagge). 

Up  to  forty  years  of  age  enteric  fever  is  proportionately  a  much 
more  fatal  disease  than  typhus.  The  reason  why  the  latter  fever 
has  a  gross  mortality  greater  than  that  of  enteric  fever  is  correctly 
stated  by  Murchison.  It  is  because  a  much  larger  proportion  of 
typhus  patients  exceed  forty  years  of  age,  and  the  death-rate  after 
that  period  of  life  is  much  in  excess  of  that  in  enteric  fever. 

Sex. — The  death-rate  in  the  London  Fever  Hospital  was  about 
1  per  cent,  higher  among  females  than  among  males. 

Season  and  Station  in  Life  do  not  materially  affect  the  death- 
rate,  but  recent  residence  in  an  infected,  locality  raises  it  consider- 
ably, and  so  do  the  intensity  of  the  poison  and  family  constitution. 
In  this  last  particular,  enteric  fever  is  akin  to  scarlatina  (page  181). 


416  enteric  fever: 

Lastly,  the  prognosis  is  bad  in  the  obese,  the  very  muscular,  the 
intemperate ;  as  well  as  in  those  who  are  the  subjects  of  gout  or  of 
kidney  disease. 

Death  is  brought  about  by  coma,  or  by  syncope,  most  commonly 
by  the  end  of  the  second,  or  early  in  the  third,  week;  by  asthenia 
or  anaemia,  in  the  third  or  fourth  week,  or  even  later ;  and  only 
rarely  by  hyperpyrexia. 

At  a  meeting  of  the  Pathological  Society  of  Dublin,  on  January 
15,  1876,  Dr.  James  Little  a  showed  the  intestinal  lesions  in  a  case 
of  acute  enteric  fever  in  a  young  woman  who  sickened  on  January 
2,  with  sore  throat  and  vomiting,  and  died  on  the  8th — that  is,  on 
the  seventh  day  of  her  illness. 

The  complications  which  most  frequently  terminate  fatally 
are :  perforation,  peritonitis,  intestinal  haemorrhage,  pulmonary 
congestion,  pneumonia,  bronchitis,  and  diarrhoea. 

Pathological  Anatomy. — Enteric  fever  differs  from  both  typhus 
and  relapsing  fever  in  the  almost  invariable  presence  of  specific 
lesions,  particularly  in  the  glandular  structures  of  the  ileum 
and  of  the  mesentery.  But  this  fact  is  in  no  way  subversive 
of  the  doctrine  that  enteric  fever,  like  typhus  or  relapsing  fever,  is 
an  essential  disease.  The  words  of  Fordyce,  quoted  by  Graves,  t> 
are  exactly  applicable: — "Fever  is  a  disease  which  affects  the 
whole  system  ;  it  affects  the  head,  trunk,  and  extremities  ;  it  affects 
the  circulation,  absorption,  and  the  nervous  system ;  it  affects 
the  body,  and  it  affects  the  mind;  it  is  therefore  a  disease  of  the 
whole  system,  in  the  fullest  sense  of  the  term.  It  does  not,  how- 
ever, affect  the  various  parts  of  the  system  uniformly  and  equally, 
but,  on  the  contrary,  sometimes  one  part  is  more  affected  than 
another." 

k' In  several  specific  fevers,"  says  Hilton  Fagge,c  "  we  find,  in 
addition  to  the  universal  'intoxication'  with  the  poison,  that  it 
fixes  itself  peculiarly  in  certain  foci,  as  we  may  call  them,  where  it 

a  Dubl.  Journ.  of  Med.  Science.     Vol.  LXII.,  page  60.     1876. 

b  Clinical  Medicine.     New  Syd:  Soc.     1884.     Vol.  I.,  page  121. 
'     c  Text- Book  of  the  Principles   and   Practice  of  Medicine.     Third  Edition. 
Vol.  I.,  page  151     Loudon:  J.  &  A.  Churchill.     1891. 


ENTERIC    FEVER.  417 

produces  definite  local  lesions.  Thus  measles  particularly  affects 
the  respiratory  mucous  membranes,  and  scarlet  fever  the  throat. 
But  nowhere  is  this  localisation  of  the  disease  so  remarkable  as  in 
enteric  fever.  In  fact,  so  striking  and  clinically  important  are  the 
local  lesions  that  it  was  possible  for  Broussais  and  his  school  to 
regard  them  as  the  primary  disease,  and  the  fever  as  merely  a 
symptomatic  result.  Probably  the  '  typhoid  deposits,'  as  they 
used  to  be  called,  in  the  intestine,  are  to  be  regarded  as  infective 
granulomata,  produced,  like  the  products  of  tubercle  and  lepi*osy, 
by  the  local  action  of  specific  bacilli." 

The  morbid  anatomy  of  enteric  fever  is  thus  epitomised  by 
Murchison  : — 

1.  The  agminated  or  solitary  glands  of  the  ileum,  the  mesenteric 
glands,  and  probably  the  spleen,  are  invariably  diseased. 

2.  Many  other  secondary  lesions  are  found,  which  are  not  constant 
or  essential.  The  chief  of  these  are — peritonitis,  granular  or  other 
degenerations  of  the  liver,  kidneys,  heart  and  voluntary  muscles, 
ulcerations  of  various  mucous  surfaces,  pneumonia,  bronchitis  and 
hypostatic  congestion  of  the  lungs,  and  an  increase  of  intra-cranial 
fluid.  There  are  no  signs  of  inflammation  in  the  brain,  or  of  its 
membranes,  to  account  for  the  cerebral  symptoms. 

3.  There  is  no  specific  typhous  exudation,  and  no  evidence  that 
the  secondary  lesions  are  due  to  the  deposit  of  a  material  like  that 
found  in  the  intestinal  and  mesenteric  glands. 

4.  The  enlargement  of  the  intestinal  and  mesenteric  glands  is 
not  due  to  any  attempt  at  elimination,  but  to  inflammation,  which 
is  probably  excited  by  absorption  of  a  poison  in  the  bowel. 

In  1864,  Zenker  a  pointed  out  two  kinds  of  degeneration  in  the 
fibres  of  voluntary  muscles  in  enteric  fever.  Some  of  these  fibres 
become  granular ;  others  undergo  conversion  into  a  glassy-looking 
(hyaline)b  substance,  in  which  no  striae  can  be  recognised,  and 
which  splits  up  transversely  into  discs.     The  change  is  especially 

a  Ueber  die  Vcranderungen  cler  wilkuhrlichen  Mttskeln  im  Typhus  ahdominalis. 
Leipzig.     1864. 

b  Gk.  vdKtvos,  of  crystal,  or  glass,  from  vaAos,  any  kind  of  clear,  transparent 
stone,  hence  glass  (Lat.  vitreum). 

2    E 


418  ENTERIC    FEVER. 

marked  in  the  adductors  of  the  thighs  and  in  the  recti  abdominis. 
Daring  life,  muscles  thus  affected  become  soft  and  pliable.  Hoff- 
mann has  shown  that  similar  forms  of  degeneration  occur  in  the 
tongue,  accounting  perhaps  for  its  tremulousness.  Zenker  himself 
remarked  that  the  changes  now  described  are  not  peculiar  to  enteric 
fever,  but  may  take  place  in  other  febrile  diseases,  if  sufficiently 
severe  and  protracted. 

The  heart  is  soft  and  pale  in  fatal  cases,  with  dilatation  of  the 
right  and  sometimes  of  the  left  ventricle.  Its  muscular  fibres  are 
more  or  less  granular  and  may  have  lost  their  transverse  striation. 
Zenker  a  once  observed  hyaline  degeneration. 

The  liver  is  softened,  on  section  presenting  a  pale  or  "  clayey  " 
look.  Examined  microscopically,  its  cells  are  found  to  be  granular 
and  disintegrating.  Minute  gray  nodules  are,  according  to  Wagner 
and  other  German  pathologists,  often  found  in  the  substance  both 
of  the  liver  and  of  the  kidneys;  the  epithelium  of  the  last-named 
organs  are  the  seat  of  cloudy  swelling  and  granular  degeneration. 

Hoffmann  described  the  nerve-cells  in  the  great  basal  ganglia  of 
the  brain  as  being  deeply  pigmented.  He  also  found  an  enormous 
overgrowth  of  cells  in  the  acini  of  the  salivary  glands  and  of  the 
pancreas,  which  structures,  according  to  this  authority,  feel  un- 
usually hard  and  dense. 

The  larynx  is  sometimes  ulcerated.  Hoffmann  observed  such  a 
state  of  things  in  28  out  of  250  cases.  This  lesion  has  been  already 
described  (see  page  396). 

It  will  be  necessary  to  treat  of  the  more  specific  lesions  of  enteric 
fever  in  a  separate  chapter. 

a  Loc.  cit.     See  also  Chapter  XVIII.,  pages  178  &  179. 


419 


CHAPTER  XLIII. 
Intestinal  and  Splenic  Lesions  of  Enteric  Fever. 

Specific  Lesions  of  the  small  intestine,  mesenteric  glands,  spleen. — The 
stomach,  duodenum,  and  jejunum  usually  healthy  or  seat  of  non-specific  lesions. — 
Neighbourhood  of  ileo-caecal  valve,  the  chief  seat  of  disease  in  both  ileum  and 

caecum. — "Entcrica  sine  enlcritide.'' — "  Infective  Granuloma"  (Hilton  Fagge). 

The  Intestinal  Lesion  :  its  four  stages— (1.)  enlargement  and  infiltration 
(2.)  softening  and  ulceration;  (3.)  "typhoid  ulcer;"  (4.)  cicatrisation. — 
Plaques  dures  et  molles  (Louis). — Plaques  reticidees  et  gaufrtes  (Chomel). — 
Characters  of  the  "Typhoid  ulcer." — "  Atonic  ulcers." — "  Shaven-beard  "  appear- 
ance {I'etat  pointille). — Perforation  of  the  peritoneum. — Lesions  of  the 
Mesenteric  Glands.— Lesions  of  the  Spleen  :  Putrilage,  abscess. 

As  the  brun£  of  the  onslaught  of  the  specific  poison  falls  in  scarla- 
tina on  the  throat,  in  measles  on  the  respiratory  mucous  membranes, 
in  smallpox  on  the  skin,  and — shall  I  add — in  pneumonic  fever  on 
the  lungs,  so  in  enteric  fever  the  battle-field  is  first  and  chiefly  the 
small  intestine,  the  neighbouring  mesenteric  glands,  and  the  spleen. 
The  stomach,  notwithstanding  the  frequent  occurrence  of  anorexia, 
nausea,  and  vomiting,  in  many  cases  escapes  all  pathological  change  ; 
in  others  the  morbid  appearances  which  it  may  present — for  example, 
increased  vascularity,  softening,  mammillation,11  and  superficial 
ulceration  (Murchison) — are  inconstant  and  non-essential.  They 
may  be  observed  with  equal  frequency  after  death  from  other 
diseases.  Louis  long  ago  pointed  out  that  "la  fievre  typhoide" 
had  no  more  claim  to  the  name  of  gastro^enterite,  than  pneumonia 
had  to  that  of  gastro-peripneumonie. 

The  duodenum  and  the  jejunum  are  usually  healthy  in  enteric 
fever,  and  so  also  may  be  the  greater  part  of  the  ileum. 

But,  starting  from  the  ileo-ccecal  valve,  morbid  changes  are 
found  to  extend  upwards  into  the  caecum  and  ascending  colon  in 
about  one-third  of  the  fatal  cases ;  but  more  particularly  and  much 

a  Lat.  Mamilla,  a  nipple.     Fr.  mamelonnation,  the  condition  of  bein°-  mam- 
millated,  that  is,  of  having  (or  presenting)  nipple-like  prominences. 


420  ENTERIC    FEVER. 

more  frequently — backwards  into  the  ileum,  in  some  instances  only 
for  a  few  inches,  in  others  for  two  or  three  feet,  or  further. 

These  morbid  changes  affect  both  the  solitary  glands  and  the 
agrainated  glands  (Peyer's  patches)  of  the  ileum,  and  also  the 
solitary  glands  of  the  colon.  But  the  distribution  of  the  lesions  is 
most  variable.  In  some  cases  the  solitary  glands  entirely  escape ; 
in  others,  the  glands  of  the  ileum  are  alone  attacked ;  in  others, 
those  of  the  caecum  suffer ;  in  a  few  the  lesions  can  be  traced  to  the 
sigmoid  flexure  or  even  to  the  rectum  (Hilton  Fagge). 

In  very  exceptional  cases,  Peyer's  patches  remain  unaffected, 
and  the  solitary  glands  bear  the  whole  brunt  of  the  disease. 
Murchison  saw  two  examples  of  this  variety,  which  Cruveilhier 
designated  la  form  pustuleuse.  More  commonly,  Peyer's  patches  are 
the  selected  seat  of  the  morbid  changes,  but  even  then  the  diseased 
processes  seem  to  start  from  the  ileo-csecal  valve,  and  to  extend 
backwards  into  the  ileum  only  for  a  comparatively  short  distance. 

This  apparent  caprice  of  distribution  of  pathological  changes 
suggested  to  Dr.  Hilton  Fagge  the  question  whether  there  may  not. 
be  some  cases  of  enteric  fever  in  which  no  glands  suffer  at  all.  In 
a  specimen  exhibited  by  him  to  the  Pathological  Society  of  London 
in  1875,  the  only  lesions  in  the  intestines  were  the  following : — 
"  One  ill-defined  purplish  red  patch,  of  about  the  size  of  a  shilling, 
situated  a  foot  above  the  valve ;  and  a  little  higher  up  another 
patch,  presenting  similar  characters,  except  that  in  its  centre  there 
was  a  darker  spot  the  size  of  a  pea,  with  a  breach  of  surface, 
visible  only  when  it  was  examined  under  water."11  Hilton  Fagge 
considered  that  it  is  by  no  means  unlikely  that  in  mild  cases  of 
enteric  fever,  such  as  never  could  prove  fatal  except  by  some 
accident,  the  intestinal  lesions  are  often  very  slight,  and  may 
possibly  in  rare  cases  be  altogether  absent.  This  view  is,  of  course, 
diametrically  opposed  to  the  dogmatism  of  Murchison,b  who  speaks 
of  "  the  specific  lesions,  which  are  invariably  present" 

*A  Case  of  Enteric  Fever  ivith  extreme  ulceration  of  the  Larynx,  and  hut  little 
affection  of  the  Ileum.  Trans,  of  the  Path.  Soc.  of  London.  1876.  Vol.  XXVII., 
page  40. 

h  Treatise  on  the  Continued  Fevers.    Third  Edition.     1881.     Page  617. 


ENTERIC    FEVER.  421 

But  is  such  dogmatism  philosophical,  or  in  accordance  with 
analogy  ?  Sure,  if  we  may  have  Variola  sine  variolis,  Scarlatina 
sine  angina,  Morbilli  sine  catarrho,  we  may  expect  occasionally  to 
meet  with  Enterica  sine  enteritidc.  Dr.  Stokes,"  no  doubt,  went  too 
far  when  he  said  :  "  It  would  be  more  philosophical  to  say  that  no 
form  of  fever  has  any  special  anatomical  change  ;  that  where  such 
does  take  place  it  is  of  a  secondary  character ;  and  that,  when  it 
arises  in  the  digestive  system,  it  is  more  frequently  observed  in  one 
form  of  fever  than  in  another."  Yet  there  is  a  kernel  of  truth  in 
such  a  statement,  and  so  long  as  the  essential  or  specific  nature  of 
each  febrile  disease  is  admitted,  so  long  must  we  look  upon  the 
local  lesions  as  secondary,  and  therefore  accidental  rather  than 
essential. 

At  a  meeting  of  the  Societe  des  Hopitaux  de  Paris,  March,  1890, 
Dr.  Vaillard  described  the  following  case : — A  soldier  after  an 
attack  of  influenza  became  very  ill,  suffering  from  stiffness  in  the 
neck,  headache,  coma,  constipation  ;  temperature,  104°  F.  Death 
on  the  10th  day.  At  the  autopsy  were  discovered  hyperemia  of 
the  meninges  and  lungs,  and  enlargement  of  the  spleen,  while  the 
intestines  were  perfectly  healthy.  Cultivation  experiments  showed 
the  presence  of  an  organism,  which  appeared  to  be  the  bacillus  of 
typhoid,  in  the  spleen,  lungs,  and  medulla.  A  streptococcus  was  also 
present.  Vaillard  believes  that  this  was  a  case  of  enteric  fever 
without  the  usual  symptoms. 

In  the  discussion  which  ensued,  Dr.  Chantemesse  stated  that  he 
had  found  the  typhoid  bacillus  in  a  dead-born  foetus,  whose  mother 
aborted  during  an  attack  of  typhoid.  Its  intestine  was  perfectly 
healthy.  It  had  died  of  typhoid  septicaemia.  In  another  case 
which  he  had  observed  a  man  died  of  typhoid.  Many  typhoid 
bacilli  were  found  in  his  organs,  but  the  intestine  was  perfectly 
healthy,  with  the  exception  of  one  ulcer  of  the  size  of  a  lentil. 

These  observers  therefore  conclude  that  there  may  be  in  rare 
cases  a  typhoid  septicaemia  without  any  local  lesions. 

On  January  23,  1891,  Dr.  Sidney  Phillips b  submitted  to  the 

a  Lectures  on  Fever.     1874.    Page  238. 

h  Trans,  of  the  Clin.  Soc.  of  London.     Vol.  XXIV.,  page  104.      1891. 


422  ENTERIC    FEVER. 

Clinical  Society  of  London  notes  of  two  cases  of  typhoid  fever,  fatal 
at  a  late  period  of  the  disease  without  ulceration  of  the  intestine. 

On  November  27,  1880,  I  laid  before  the  Pathological  Society 
of  Dublin  specimens  from  a  case  of  enteric  fever  in  which  there 
was  no  disease  of  the  glands  of  the  ileum,  while  the  spleen  was 
extremely  large,  soft,  and  friable,  and  in  a  state  of  putrilage.  The 
ileum  was  carefully  examined.  In  places  the  mucous  membrane 
was  congested  to  the  extent  of  two  or  three  inches,  but  there  was 
not  the  slightest  trace  of  past  or  present  disease  of  the  agminated 
or  solitary  glands.  Peyer's  patches  were,  indeed,  apparently  less 
distinct  than  usual.  They  were  not  hyperbaric,  and  did  not  present 
the  "shaven-beard"  appearance.  This  was,  no  doubt,  an  example 
of  what  is  now  known  as  "  spleno-typhoid."     (See  page  406.) 

At  the  same  time,  in  an  overwhelming  majority  of  cases,  charac- 
teristic lesions  are  certainly  present  in  the  intestines  of  enteric 
fever  patients.  These  I  will  now  try  to  describe  as  briefly  as 
may  be. 

Certain  facts  led  Dr.  Hilton  Fagge  to  the  belief  that  during  the 
period  of  incubation  the  invading  Bacilli  typhosi  produce  a  local 
"infective  granuloma,"  and  that  this  remains  latent  until  they 
(or  their  spores)  leave  the  intestinal  follicles  by  the  lymphatic 
channels,  and  overspread  the  entire  organism  in  swarms. 

Be  this  as  it  may,  the  primary  local  lesions  in  the  intestines  run 
a  course  somewhat  parallel  to  that  of  the  symptoms,  and  with 
Bretonneau  (of  Tours),  Trousseau,  and  Liebermeister,  Ave  may 
divide  the  history  of  the  development  and  retrocession  of  these 
lesions  into  four  several  periods  of  seven  days  each,  or  weeks  ;  or, 
with  Murchison,  we  may  describe  the  lesions  as  passing  through 
four  stages,  although  the  disease  is  often  arrested  at  the  end  of  the 
first.  These  stages  closely  correspond  with  periods  of  seven  days 
each,  so  that  there  is  no  contradiction  between  the  several  autho- 
rities I  have  just  named.  The  stages  are: — 1.  The  stage  of 
enlargement  of  the  intestinal  glands  (Fr.  Engouemenf).  2.  The 
stage  of  softening  and  ulceration  (Fr.  JOetage  furonculeuse).  3.  The 
stage  of  the  genuine  "  typhoid  ulcer  "  (Fr.  Le  boarbillon).  4.  The 
stage  of  cicatrisation. 


ENTERIC    FEVER.  423 

I.  The  first  stage  probably  begins  with  the  disease,  perhaps 
even  in  the  closing  days  of  the  period  of  incubation.  The  solitary 
and  agminate  glands  in  that  portion  of  the  ileum  nearest  to  the 
ileo-caecal  valve  swell,  and  become  the  seat  of  what  Liebermeister 
calls  a  medullary  infiltration.  The  neighbouring  mucous  mem- 
brane is  usually,  but  not  necessarily,  hyperamiic.  These  changes 
go  on  through  the  first  week,  so  that  by  the  eighth  day  or  so 
Peyer's  patches  are,  in  cases  which  have  proved  speedily  fatal' 
found  indurated  and  elevated  from  half  a  line  to  two  lines  above 
the  surface  of  the  bowel.  The  hardness  of  the  diseased  patches  or 
plates  varies.  If  marked,  the  patches  form  the  plaques  dures  of 
Louis.  If  the  enlargement  is  only  slight,  and  the  consistence  of 
the  patches  is  soft,  they  are  the  plaques  rnolles  of  Louis.  These 
are  the  plaques  reticulees  (the  network  plates),  and  the  plaques 
gaufrees  (the  honeycombed  plates)  of  Chomel.  Dr.  T.  J.  Maclagan 
endeavoured  to  show  that  the  plaques  molles  are  always  excited 
by  a  secondary  inoculation  with  poison  thrown  off  by  a  plaque 
dure — in  other  words,  that  the  plaques  dures  are  primary,  and  the 
plaques  molles  are  secondary  lesions.  This  view  has  not  been 
confirmed. 

As  is  well  known,  a  Peyer's  patch  is  a  roundish  or  elliptical 
area,  situated  at  the  free  border  of  the  intestine,  I'd  centimetres 
in  length,  7'2  centimetres  in  breadth,  with  its  long  axis  corre- 
sponding to  that  of  the  intestine  (at  least,  in  the  ileum),  and  con- 
sisting of  twenty  or  more  lymph  follicles  grouped  together  and 
separated  from  each  other  only  by  thin  prolongations  of  the  sub- 
mucous tissue  (E.  Verson  a).  In  enteric  fever,  the  proper  structure 
of  a  Peyer's  patch  first  becomes  enlarged  by  a  proliferation  of  its 
cellular  elements,  the  surrounding  connective  tissue  next  becomes 
involved,  until,  at  last,  the  whole  patch  is  converted  into  a  conti- 
nuous mass  of  altered  gland-tissues.  This,  according  to  Murchison, 
is  what  happens  in  the  case  of  the  plaques  dures.  In  the  plaques 
molles  the  morbid  process  stops  short  of  this-^the  glandules  become 
enlarged,  but  not  to  such  an  extent  as  to  run  into  one  another. 

n  Manual  of  Human  and  Comparative  Histology.  Edited  by  S.  Strieker. 
Vol.  I.,  page  5G5.     New  Syd.  Soc.     1870. 


424  ENTEEIC    FEVER. 

II.  The  second  stage  is  nearly  completed  by  the  end  of  the 
second  week.  The  infiltration  of  Peyer's  patches  gradually  pro- 
gresses, and  some  of  the  swollen  patches  ulcerate  and  become 
partially  or  wholly  necrotic — the  process  leading  to  the  formation 
of  sloughs  stained  a  bright  ochre  or  yellow  by  the  bile  (Lieber- 
meister).  Wm.  Budda  considered  that  "this  yellow  matter  is  the 
peculiar  '  typhoid  matter,'  whose  presence  is  typical  of  the  disease, 
and  whose  formation  and  elimination  constitute  the  essence  of  the 
intestinal  process."  This  view  is  not  now  entertained  by  any 
authorities  on  enteric  fever,  so  far  as  I  know. 

Ulceration  seems  sometimes  to  begin  as  an  abrasion  of  the  surface 
of  the  diseased  follicles,  and  gradually  to  extend  through  their 
substance ;  much  oftener,  however,  the  whole  or  most  of  the  infil- 
trated tissue  dies  in  a  mass,  forming  a  soft,  shreddy,  flocculent 
slough  of  a  bright  ochre  colour  as  above  (Hilton  Fagge).  The 
former  process  affects  the  plaques  molles,  the  latter  the  plaques  dures 
(Murchison). 

III.  The  stage  of  the  "  typhoid  ulcer  "  is,  in  Murchison's  words, 
that  which  intervenes  between  the  commencement  of  ulceration 
and  the  commencement  of  cicatrisation.  It  is  impossible  to  fix  its 
limits,  as  they  vary  in  different  patient?,  and  in  different  ulcers  of 
the  same  bowel.  For  the  sake  of  convenience,  however,  we  may 
say  that  ulceration  usually  takes  place  after  the  9th  or  10th  day, 
and  in  the  third  week  sloughs  fall  off,  the  cleaning  off  of  the 
ulcers  being  in  general  well-nigh  completed  by  the  21st  day 
or  so. 

"  Typhoid  ulcers"  are  distinguished  by  the  following  characters :  — 

1.  Situation. — In  the  lower  third  of  the  ileum,  chiefly  near  the 
iieo-ca3cal  valve. 

2.  Size. — They  vary  in  diameter  from  one  line  to  an  inch  and  a 
half. 

3.  Form. — If  their  seat  is  a  Peyer's  patch,  they  are  elliptical; 
if  a  solitary  gland,  circular ;  or  they  may  be  irregular  from  the 
coalescence  of  several  ulcers. 

a  Typhoid  Fever :  its  Nature,  Mode  of  Spreading,  and  Prevention.  By  William 
Budd,  M.D.,  F.R.S.     London  :  Longmans,  Green  &  Co.     1873.     Page  47. 


ENTERIC    FEVER.  425 

4.  Anatomical  Relations.  —  The  elliptical  ulcers  are  always 
opposite  the  attachment  of  the  mesentery,  and  their  long  diameter 
corresponds  to  ihe  longitudinal  axis  of  the  gut. 

5.  Outline. — Their  margin  is  formed  by  a  well-defined  fringe  of 
mucous  membrane,  of  a  purple  or  slaty-gray  colour,  one  line  or 
more  in  width,  detached  from  the  submucous  tissue.  There  is  no 
thickening  or  hardening  of  the  edge,  as  in  the  tubercular  ulcer. 

6.  Base. — This  is  formed  by  the  submucous  tissue,  or  by  the 
muscular  coat  of  the  intestine,  or  by  the  peritoneum. 

As  the  sloughs  fall  off,  losses  of  substance  of  variable  extent 
and  depth  take  place,  involving,  it  may  be,  the  muscular  coat,  and 
even  the  peritoneum.  In  the  latter  case,  of  course,  perforation 
occurs. 

IV.  At  some  time  during  the  fourth  week,  the  reparative  process 
called  cicatrisation  begins,  and  may  continue  for  a  long  time — in 
the  case  of  an  individual  ulcer  it  occupies  about  a  fortnight. 
Cicatrisation  begins  in  the  ulcers  nearest  the  caecum,  and  proceeds 
upwards.  The  floor  of  the  ulcer  becomes  covered  with  a  thin,  gray, 
shining  layer  of  granulation  tissue,  which  is  dove-tailed,  so  to 
speak,  between  the  muscular  coat  and  the  detached  fringe  of 
mucous  membrane.  The  ulcer  then  heals  by  a  gradual  growth 
of  mucous  membrane  from  the  edges  towards  the  centre — an 
epithelial  covering  being  slowly  formed  over  the  ulcer,  adherent 
at  first,  but  afterwards  becoming  movable  on  the  submucous  coat. 
The  gland-structure  which  has  sloughed  away  is  not  regenerated. 
The  cicatrix  is  slightly  depressed,  firmer,  less  vascular,  and  smoother 
than  the  surrounding  mucous  membrane.  When  held  up  to  the 
light,  the  bowel  appears  thinner  at  the  part.  There  is  no  sur- 
rounding puckering,  and  the  calibre  of  the  gut  is  not  narrowed 
(Murchison).  According  to  Chomel,a  all  traces  of  the  ulcers 
disappear  after  a  short  time,  but  Rokitansky  b  has  recognised  them 
thirty  years  after  an  attack  of  enteric  fever. 

Occasionally  the  process  of  cicatrisation  is  much  prolonged, 
owing  to  the  ulcers  becoming  chronic,  or,  as  some  pathologists  say, 

a  Lerons  cle  Cliniquc  Mtdicale.     Tome  I.     Paris.     1834. 
bPath.Anat.     Syd.  Soc.     London.     1852.     Vol.  II.,  page  73. 


426  enteric  fever. 

atonic.  These  chronic  or  atonic  ulcers  after  the  fourth  week  may 
cause  severe  diarrhoea,  or  may  lead  to  fatal  perforation. 

The  pathological  changes  just  described  may  proceed  simulta- 
neously in  different  parts  of  the  small  intestine — being  most  ad- 
vanced near  the  ileo-csecal  valve,  where  cicatrisation  may  have 
already  begun  while  fresh  infiltrations  are  only  taking  place  in 
portions  of  the  bowel  at  a  distance  from  that  centre  of  disease. 
This  state  of  things  is  beautifully  shown  in  the  coloured  Plate  which 
forms  the  Frontispiece  to  this  work.  The  original  drawings,  from 
which  the  lithograph  was  skilfully  and  artistically  produced  by 
Mr.  John  Falconer,  of  53  Upper  Sackville-street,  Dublin,  were 
executed  in  water-colours  at  my  request  by  my  friend  and  pupil, 
the  late  Mr.  Edmund  P.  Henn,  at  the  Meath  Hospital  and  County 
Dublin  Infirmary.  They  faithfully  represent  the  appearances  in  a 
fatal  case  of  enteric  fever  under  my  care  in  the  year  1879. 

Fig.  1  shows  two  Peyer's  patches  and  four  solitary  glands  in  the 
first  stage  of  the  typhoid  disease  in  the  ileum  at  a  distance  of  some 
two  feet  from  the  ileo-ccecal  valve.  Fig.  2  represents  the  com- 
mencement of  the  second  stage — that  of  ulceration — at  a  lower 
level  in  the  ileum.  It  will  be  seen  that  at  two  points  the  tumefied 
Peyer's  patch  is  beginning  to  ulcerate,  and  already  a  bright  yellow 
coloration  is  commencing  to  show  itself.  Fig.  3  represents  4  inches 
of  the  ileum  nearest  to  the  valve,  and  also  the  neighbouring  mesen- 
teric glands — the  latter  greatly  swollen.  In  this  case  the  slough  is 
fully  formed,  and  is  about  to  be  cast  off  from  a  patch  between  two 
and  three  inches  from  the  valve ;  while  the  slough  from  a  large 
ulcer  close  to  the  valve  itself  has  already  been  detached  in  part  and 
cast  off. 

One  is  not  to  suppose  that,  in  every  case  of  enteric  fever,  the 
local  lesions  in  the  intestines  run  through  all  the  four  stages  which 
have  been  just  described.  On  the  contrary,  the  instances  are  not 
few  in  which  retrograde  changes  may  occur  as  early  as  the  close 
of  the  first  week.  In  the  milder  cases,  the  swelling  (or,  engouement)  of 
Peyer's  patches  may  gradually  subside  by  degeneration  and  absorp- 
tion until  both  patches  and  separate  follicles  return  to  their  normal 
state.     If  the  follicles  of  a  Peyer's  patch  retrograde  faster  than  the 


ENTEKIC    FEVEK.  427 

interstitial  tissue,  this  latter  may  for  a  time  form  a  projecting  net- 
work {plaques  a  surface  reticulee).  Frequently,  the  swollen  follicles 
soften  and  break  down,  so  that  the  patches  again  present  a  reticu- 
lated' appearance.  Especially  in  this  case,  but  sometimes  with 
simple  swelling,  numerous  little  ecchymoses  occur,  so  as  to  pro- 
duce a  punctate  pigmentation  of  the  patches.  This  gives  a  dotted 
appearance  to  the  patches — the  shaven-beard  appearance  of 
English,  the  etat  pointille  of  French  writers.  Hilton  Fagge  denies 
that  this  condition  is  peculiar  to  enteric  fever — in  this  opinion  he 
is  borne  out  by  Murchison,  who  has  seen  this  change  in  case3  of 
typhus,  cholera,  phthisis,  and  so  on. 

Perforation  of  the  peritoneum  may  take  place,  according  to 
Murchison,  in  one  of  three  ways. 

1.  It  may  be  due  to  disintegration,  or  to  an  extension  of  the 
ulcerative  process.  The  opening  is  then  always  minute  and  circular, 
just  large  enough  to  admit  a  pin  or  a  stocking  wire.  This  is  the 
most  common  form  of  perforation. 

2.  A  portion  of  the  peritoneum  may  slough,  and  perforation  may 
result  from  the  partial  or  complete  detachment  of  the  slough.  The 
openings  are,  in  this  case,  many  and  of  considerable  size. 

3.  The  perforation  may  result  from  rupture  of  the  denuded 
peritoneum  at  the  base  of  one  of  the  destroyed  Peyer's  patches. 

Among  twenty-nine  cases  of  perforation,  of  which  Murchison  had 
accurate  notes,  the  first  form  was  present  in  fifteen,  the  second  in 
ten,  and  the  third  in  four  cases. 

Dr.  Robert  S.  Archer, a  formerly  Physician  to  the  Netherfield 
Fever  Hospital,  Liverpool,  in  narrating  the  clinical  histories  of  six 
cases  of  perforation  of  the  intestine  in  enteric  fever,  very  properly 
draws  a  distinction  between  perforation  in  the  proper  sense  of  the 
term  and  rupture  of  the  peritoneal  coat  at  the  base  of  an  ulcer.  In 
the  case  of  perforation,  the  process  would  seem  to  be  a  gradually 
progressive  necrotic  one,  involving  in  order  all  the  coats  of  the 
gut  from  within  outwards,  the  peritoneal  coat  at  length  suc- 
cumbing to  the  destructive  change.  The  perforation  is  in  this 
case  usually  more  or  less  circular,  and  its  edges  are  somewhat 
a  Dull.  Journ.  of  Med.  Science.    Vol.  LXXXIV.,  page  90.     1887. 


428  .  ENTERIC    FEVEK. 

thickened  by  lymphy  deposit.  Its  size  may  vary  from  a  pin-hole 
opening  to  one  half  an  inch  or  more  in  diameter.  Lymph  is  thrown 
out  around  the  opening,  and  adhesions  are  in  process  of  formation. 

In  rupture  of  the  peritoneal  coat,  on  the  other  hand,  the  ulcera- 
tive process  seems  to  stop  suddenly  at,  or  has  not  extended  to,  the 
serous  membrane,  and  the  latter  gives  way  from  the  pressure  of 
fasces  or  gas.  In  this  case  the  opening  takes  the  form  of  a  more  or 
less  regular  angular  slit,  with  little  or  no  deposit  of  lymph,  and  the 
edges  may  be  brought  together  with  considerable  accuracy. 

The  Mesenteric  Lymph-glands  are  very  commonly  enlarged  in 
enteric  fever — no  doubt  from  absorption  by  the  lacteals  of  contagion 
from  the  affected  parts  of  the  intestines  (Hilton  Fagge).  Hence  it 
is  that  the  swelling  of  the  glands  is  most  developed  in  these  parts 
of  the  mesentery  which  correspond  to  the  diseased  portions  of  the 
intestine.  The  swollen  glands  may  not  be  larger  than  a  hazel-nut, 
but  some  may  be  as  large  as  a  horse-chestnut,  or  a  pigeon's  egg,  or 
even  a  hen's  egg.  At  first  the  swollen  glands  are  hyperaamic,  rosy 
red  or  bluish-red,  tense  ;  afterwards,  they  become  paler,  assuming 
a  pinkish  or  grayish  tint.  Suppuration  sometimes  occurs,  while 
caseation  or  the  deposition  of  calcareous  salts  forms  part  of  the 
ordinary  retrograde  process.  Examined  histologically,  the  enlarged 
glands  show  a  cellular  hyperplasia — or  numerical  hypertrophy — 
with  hypertrophy  of  the  interstitial  connective  tissue  (Liebermeister.) 

Fig.  3  in  the  Frontispiece  exhibits  very  well  the  great  enlarge- 
ment of  the  mesenteric  glands  near  the  ileo-cascal  valve,  which  is  so 
often  present. 

In  some  cases  other  lymphatic  glands  are  engaged  also.  For 
example,  the  retroperitoneal  glands,  the  bronchial  glands,  and 
others — but  these  are  secondary  and  accidental  phenomena,  usually 
due  to  non-specific  irritations. 

The  Spleen  is  commonly  enlarged  and  softened,  being  the  seat 
of  changes  which  are  strictly  analogous  to  those  observed  in  the 
intestinal  follicles  and  the  mesenteric  glands.  The  enlargement 
begins  early  in  the  fever,  and  can  be  detected  after  the  middle  of 
the  first  week.  At  this  period,  the  organ  is  tense,  firm,  and  hyper- 
aemic.     The  spleen  increases  in  size  up  to  the  third  week  and  sub- 


ENTERIC   FEVER.  429 

sides  again  in  the  fourth  week.  The  enlargement  is  most  marked 
in  young  subjects,  and  may  be  wanting  in  elderly  persons.  Louis 
found  the  spleen  softened  in  thirty-four  out  of  forty-six  cases,  and 
in  seven  it  was  reduced  to  a  mass  of  "  putrilage  " a  (JMurchison). 
According  to  Rokitansky,  the  enlarged,  softened  spleen  is  liable  to 
spontaneous  rupture.  Bacilli  have  frecpjently  been  found  in  the 
spleen  in  enteric  fever.  Their  discharge  into  the  general  circula- 
tion when  the  organ  suddenly  subsides  may  account  for  some  of  the 
cases  of  relapse  which  have  been  recorded. 

Rarely,  abscess  of  the  spleen  occurs.  Murchison's  vast  ex- 
perience gives  only  two  cases  of  this  lesion,  and  he  quotes  five  others 
from  different  authors.  In  the  Buhl.  Journ.  of  Medical  Science  for 
February,  1880  (Vol.  LXXXI.,  page  109),  will  be  found  an 
interesting  case  in  a  boy,  aged  fourteen,  which  was  reported  by 
Dr.  Robert  S.  Archer,  then  Physician  to  the  Netherfield  Hospital, 
Liverpool. 

Such  are  the  primary  local  lesions  of  the  disease  before  us. 
The  secondary  local  lesions  are  principally  of  the  nature  of  a 
parenchymatous  degeneration  with  cloudy  swelling  of  various 
organs — such  as  the  liver,  heart,  and  voluntary  muscles  {Myositis 
typhosd) — which  is  not  in  any  way  characteristic  of  enteric  fever, 
but  which  is  forthcoming  in  all  febrile  affections  in  which  pyrexia 
is  sufficiently  intense  and  persistent. 

a  Pultaceous  or  pappy  matter,  which  forms  in  the  course  of  certain  necrotic 
or  gangrenous  affections.     Lat.  putrilago — rottenness,  corruption,  putrefaction. 


430 


CHAPTER   XLIV. 
The  Prophylaxis  or  Enteric  Fever. 

Measures  to  be  adopted  for  Checking  the  Development  of  the  Fever 
Poison  :  Efficient  drainage  system. — Improved  water-closets. — Drinking  water 
to  be  taken  direct  from  the  main. — Use  of  chemical  disinfectants. — Measures 
for  Preventing  the  Propagation  of  the  Fever  Poison  :  Disinfection  of 
excreta. — Treatment  of  bedding  and  body  linen. — Ventilation  of  sick  room. — 
Trace  origin  of  first  case  of  fever  in  each  outbreak. 

"  A  man,"  says  Liebermeister,a  "  who  avoids  breathing  the 
exhalations  of  privies  and  sewers,  who  does  not  handle  linen  foul 
with  typhoid  dejections,  who  does  not  drink  unboiled  water  from 
infected  springs,  is  as  safe  in  a  place  where  a  typhoid  epidemic 
is  raging  as  in  one  where  not  a  case  of  the  disease  exists." 

This  aphorism  of  Liebermeister  places  in  our  hand  the  key  to  the 
preventive  treatment,  or  prophylaxis  of  enteric  fever. 

The  subject  may  be  considered  under  two  headings  — 

1.  The  measures  to  be  adopted  for  checking  the  development  of 
the  fever  poison. 

2.  The  measures  to  be  adopted  for  preventing  the  propagation 
of  the  fever  poison. 

I.  A  careful  study  of  Chapter  IV.,  and  particularly  that  portion 
of  it  which  deals  with  the  subject  of  disinfection  without  and  with- 
in the  body  (page  31-38),  will  place  the  reader  in  possession  of 
full  information  as  to  the  best  means  at  our  disposal  for  achieving 
the  first  end  in  view — the  checking  or  prevention  of  the  growth 
and  development  of  the  specific  poison  of  enteric  fever. 

It  is  a  popular  error  to  suppose  that  this  poison  is  an  offensive 
gas  which  can  easily  be  smelled.  On  the  contrary,  it  is  probably 
quite  inodorous,  although  often  accompanied  by  bad  smells,  the 
result  of  putrefaction  of  the  retained  contents  in  defective  drains. 

a  Von  Ziemssen's  Cyclopcedia  of  the  Practice  of  Medicine.  Art.  "  Typhoid 
Fever."    Vol.  L,  page  71. 


ENTERIC    FEVER.  431 

1.  The  first  essential  is  that  there  should  be  an  efficient  drain- 
age system — consisting  of  (a.)  flushing  apparatus,  (/3.)  properly 
laid,  well-ventilated,  and  securely  trapped  house-drains,  discharging 
into  (ry.)  well-constructed  public  sewers. 

This  is  not  the  place  to  enter  into  details  on  the  subject  of  house- 
drains  and  public  sewers  (I  use  these  terms  in  their  strictly  legal, 
or  technical  and  accepted  sense).  But  a  few  remarks  will,  perhaps, 
prove  useful.  They  are  based  upon  an  excellent  description  in  Mr. 
Winter  Blyth's  "Manual  of  Public  Health." 

A  house-drain  should  be  constructed  of  glazed  socket  pipes,  made 
of  pipe-clay  or  a  mixture  of  fire  and  pipe-clay — salt  or  glass-glazed. 

These  drain-pipes  should  each  be  provided  with  a  collar  or  socket 
at  one  end,  so  as  to  receive  the  spigot  end  of  the  next  pipe,  the 
joints  being  carefully  filled  in  with  Portland  cement,  unless  a  patent 
joint,  such  as  Stanford's,  is  used.  In  this  a  sort  of  ball  joint  is 
made,  and  a  little  grease  renders  all  tight.  All  joints  should  be 
water-tight.  For  ordinary  ten-roomed  houses,  4-inch  pipes  are 
ample.  Larger  houses  require  pipes  of  5  or  6  inches  diameter, 
and  country  mansions  may  require  for  the  main  drain  a  9 -inch  pipe. 

The  pipes  should  be  laid  on  a  concrete  bottom,  with  a  fall  of  at 
least  one  in  forty-eight — that  is,  4;  inch  to  a  foot.  When  one  drain 
joins  another,  the  junction  should  be  at  an  acute,  not  a  right  angle  ; 
or  in  the  form  of  a  curve — a  larger  pipe  must  receive  a  smaller, 
not  vice  versa.  Of  late  years,  special  lengths  of  pipe,  gradually 
lessening  in  diameter  from  9  to  G  inches,  or  from  6  to  5  or  4 
inches,  have  been  used  for  making  such  junctions.  Drain  pipes 
should  not,  if  possible,  be  laid  under  a  house.  When  a  drain 
changes  its  direction,  means  of  inspection  should  be  provided. 

Every  drain  should  have  an  "  inspection  chamber  "  at  its  lower 
end,  before  it  enters  the  "  intercept  ng-trap,"  which  cuts  it  off  from 
the  public  sewer,  as  well  as  a  "  fresh-air  "  inlet  in  this  same  situa- 
tion, and  a  "  ventilating  shaft,"  carried  above  the  dwelling-house 
at  the  highest  point  of  the  drain.  In  this  last-named  situation 
also  a  "  flushing-tank  "  should  be  provided,  capable  of  discharging 
into  the  drain  through  a  4-inch  pipe  not  less  than  40  gallons  of 
water  at  least  once  a  day.     It  is  a  great  mistake  to  shut  up  a  city 


432  ENTERIC   FEVER. 

residence  for  two  or  three  months  in  the  summer  season,  and  to 
return  to  it  in  autumn  without  first  causing  the  drains  to  be 
repeatedly  flushed  and  thoroughly  cleansed  and  disinfected.  I  am 
sure  mischief  to  health  is  often  caused  by  inattention  to  such 
details. 

In  addition  to  the  house-drains,  water-closets  require  attention. 
They  should  be  placed  at  the  back  of  the  house,  and  if  in  structural 
connection  with  it  a  short  lobby  or  corridor  should  be  interposed 
to  secure  cross-ventilation.  There  are  three  chief  types  of  water- 
closet — the  pan-closet,  the  valve-closet,  and  the  hopper-closet.  Of 
these,  I  mention  the  first  two  only  to  condemn  them .  The  hopper- 
closet  differs  from  both  in  having  no  mechanical  parts.  It  is 
simply  a  funnel  terminating  in  a  siphon — a  good  flush  of  water 
sweeping  the  contents  away.  An  improved  form  of  the  hopper- 
closet  is  known  as  the  "  wash-out  closet."  It  is  often  made  of 
glazed  stoneware  cast  in  a  single  piece,  and  is  cleansed  after  use 
simply  by  a  good  flush  of  water.  The  most  modern  closets  have 
neither  "  safe  "  nor  wood  casing.  The  "  safe  "  is  a  lead  tray  on 
the  floor  to  prevent  any  overflow  soaking  through. 

"  Soil  pipes,"  connecting  the  closet  with  the  drain,  should  be 
constructed  of  lead,  4  inches  in  diameter,  and  run  down  outside  the 
house,  if  feasible. 

Each  soil-pipe  should  be  freely  ventilated  by  being  carried  full 
bore,  without  curves  or  bends,  to  a  few  inches  above  the  roof-ridge. 

Under  no  circumstances  should  drinking  water  be  drawn  from 
a  water-closet  cistern  or  tank — indeed,  each  closet  should  be  fitted 
with  an  automatic  patent  flushing  tank  of  small  size,  used  for  the 
purpose  of  flushing  alone ;  while  drinking  water  should,  in  every 
instance,  be  taken  direct  from  the  water-main. 

2.  Whenever  drains  or  cesspools  are  disturbed  for  purposes  of 
cleansing,  chemical  disinfectants  should  be  freely  used,  and  the 
household  should  certainly  vacate  the  house  for  the  time  being. 
The  disinfectants  in  most  request  are  : — carbolic  acid  (phenol), 
in  solution,  one  part  in  40  parts  of  water  (2£  per  cent.) ;  copperas 
(or  ferrous  sulphate),  2  ozs.  to  one  pint  of  water ;  Burnett's  fluid 
(solution  of  chloride  of  zinc) ;  chlorinated  lime,  commonly  called 


ENTERIC    FEVER.  433 

"chloride  of  lime;"  Condy's  fluid  (a  powerful  oxidiser  and  deodo- 
riser); chloralum ;  and  dry  charcoal.  The  three  last  named  are 
disinfectants,  but  not  antiseptics  (see  Chapter  IV.,  page  31). 

II.  With  the  view  of  checking  or  preventing  the  propagation 
of  the  poison  of  enteric  fever,  the  following  means  should  in  all 
cases  be  adopted  :— •* 

1.  The  Excreta  should  be  disinfected  as  soon  as  they  are  dis- 
charged from  the  body.  Both  the  freshly  passed  evacuations  from 
the  bowels  and  the  urine  should  be  mixed  with  a  sufficient  quantity 
of  a  solution  of  carbolic  acid  (1  in  40)  or  of  ferrous  sulphate,  before 
they  pass  into  the  house  drains  or  public  sewers,  or  can  permeate  into 
the  sources  of  drinking  water.  Carbolic  acid  is  especially  useful 
for  this  purpose  because  of  its  power  of  arresting  fermentation. 

For  the  thorough  disinfection  of  fluid  or  semi-fluid  stools,  Prof. 
Uffelmann  recommends  the  following  methods :  Sulphuric,  or 
hydrochloric  acid,  diluted  with  double  the  quantity  of  water, 
should  be  mixed  with  equal  parts  of  the  faecal  matter,  and  allowed 
to  stand,  in  the  case  of  the  former  acid,  for  two  hours ;  in  the  case 
of  the  latter,  for  twelve  hours.  Jfn  using  carbolic  acid,  a  5  per 
cent,  solution  should  be  added  to  the  stools  in  equal  parts  and  left 
for  twenty-four  hours.  Corrosive  sublimate  should  be  employed 
in  a  solution  of  2  per  1,000,  with  half  a  part  per  1,000  of  hydro- 
chloric acid.  An  equal  quantity  of  this  solution  is  added  to  the 
motions  and  set  aside  for  at  least  half  an  hour,  but  preferably  for 
twenty-four  hours.  Quick-lime  ought  to  be  added  to  the  stools  in 
the  proportion  of  1\  parts  per  cent.,  and  allowed  to  remain  twenty- 
four  hours.  In  the  case  of  lime-water,  a  similar  time  should  be 
allowed  and  the  disinfectant  should  be  employed  in  the  proportion 
of  2\  parts  to  one  of  fasces. 

2.  The  bedding  and  body-linen  from  the  patient  should  be  soaked 
in  carbolised  water  (4  ounces  of  carbolic  acid  to  a  gallon  of  water). 
It  is  a  good  plan,  also,  to  boil  or  bake  these  possible  fomites  before 
they  are  sent  to  the  laundry  to  be  washed. 

3.  The  sick-room  should  be  freely  ventilated — the  purity  of  the 
air  in  the  chamber  may  be  tested  by  exposing  solution  of  per- 
manganate of  potassium  in  saucers.     The  air  is  impure  in  direct 

2  F 


434  ENTERIC    FEVER. 

proportion  to  the  rapidity  with  which  the  beautiful  purple  colour 
of  this  solution  changes  into  a  dirty  rusty  brown  tint. 

4.  When  the  first  case  of  enteric  fever  occurs  in  a  given  house, 
every  effort  should  be  made  to  trace  it  back  to  its  original  cause. 

I  am  confident  that  the  day  is  not  far  distant  which  will  place 
in  our  hands  an  unfailing  weapon  of  defence  against  the  successful 
invasion  of  the  body  by  the  Bacilli  typltosi  of  Eberth. 

A  careful  perusal  of  the  discussion  on  "  Immunity,"  which  took 
place  in  the  Section  of  Bacteriology  at  the  Seventh  International 
Congress  of  Hygiene  and  Demography,  held  in  London,  August 
10th  to  17th,  1891,  will  convince  the  reader  that  we  stand  on  the 
threshold  of  a  great  discovery — the  isolation  of  the  substances  which 
produce  an  acquired  immunity  in  the  case  of  each  of  the  infective 
micro-parasitic  diseases  ;  and  these,  of  course,  include  enteric  fever. 

In  that  discussion,  Dr.  Hans  Buchner  expressed  the  opinion  that 
these  protective  substances  were  most  probably  albuminous  bodies 
of  very  unstable  constitution,  and  of  a  very  complicated  structure, 
which  was  specifically  different  in  different  cases.  He  proposed  for 
these  the  name  of  "alexins"   (Greek,  ake^co,  I  ward  off,  defend). 

Mr.  E„  H.  Hankin,  B.A.,  Fellow  of  St.  John's  College,  Cam- 
bridge, said  that  the  discovery  of  the  bacteria-killing  power  of 
blood  serum  had  led  to  the  view  that  immunity  was  caused  by  a 
bactericidal  action  exerted  by  the  blood  and  lymph  of  an  immune 
animal.  This  bactericidal  power  was  due  to  the  presence  of  cer- 
tain bacteria-killing  substances,  to  which  the  name  "  defensive 
proteids"  had  been  given.  These  are  the  "alexins"  of  Buchner. 
They  are  divided  into  "sozins"a  and  "phylaxins."  b  Sozins  are 
defensive  proteids  present  naturally  in  the  normal  animal.  Phy- 
laxins are  present  in  animals  which  have  artificially  been  made 
immune  against  a  disease. 

The  view  of  immunity  suggested  by  the  discovery  of  these  defen- 
sive proteids  or  alexins  by  no  means  excludes  Metschnikoff's  pha- 
gocyte theory,  because  they  can  be  obtained  from  cells  which  were, 
or  could  become,  phagocytes.     (See  Chapter  III.,  page  22.) 

a  Greek  :  ca>£a>,  to  save  alive,  to  preserve. 

b  Greek  :  tp{\v£,  a  protector,  from  tyvXarrw,  to  guard. 


CHAPTER  XLV. 

Curative  Treatment  or  Enteric  Fever. 

No  Specific  for  Enteric  Fever. — Principles  of  Treatment  apply  equally  to 
this  fever  and  to  typhus.  Curative  Treatment  or  Management:  Hygiene, 
Diet,  Stimulants,  Antiseptic  Drugs: — Iodide  of  potassium,  calomel,  arsenic, 
antimony,  /3-naphthol,  salicylate  of  bismuth,  salicylate  of  magnesium,  carbolic 
acid,  the  sulphites,  turpentine,  free  chlorine,  quinine,  oil  of  eucalyptus,  cam- 
phor, creasote,  thymol,  naphthalin,  salol. 

"  There  is  no  specific  for  enteric  fever,"  writes  Alurchison,  "any- 
more than  for  typhus."  But  he  adds  :  "  Although  we  cannot  cure 
the  disease,  Ave  must  treat  it."  While  deprecating  the  nimia  dili- 
gentia  medici,  by  depletion  on  the  one  hand,  or  by  over-stimulation 
on  the  other,  he  says  that  it  must  not  be  thought  that  the  best 
treatment  is  one  of  mere  expectancy.  He  quotes,  however,  with 
approval  Baglivi's a  remark  on  "  mesenteric  fever"  made  two  cen- 
turies ago — "Sed  cpiod  pra?  cieteris  animadverto,  in  nullo  morborum 
genere,  tanta  opus  est  patientia,  expectatione,  cunctationeque,  ad 
bene  et  feliciter  medendum,  tanquam  ad  bene  curandum  febres 
mesentericas." 

The  fact  is  that  while  the  great  principles  of  treatment  of  enteric 
fever  are  precisely  the  same  as  those  which  guide  us  in  our  manage- 
ment of  typhus,  there  is  no  other  disease  which  in  the  same  degree 
taxes  to  the  uttermost  the  resources  of  the  physician.  Of  every 
"turn"  in  enteric  fever,  of  every  day  or  hour  which  marks  its 
course,  it  may  truly  be  said  :  "  Latet  anguis  in  herba."  The  atti- 
tude of  the  physician  must  be  one  of  "  armed  expectancy,"  to 
borrow  the  expressive  phrase  given  by  Dujardin-Beaumetz  b  in  1889 
to  that  form  of  symptomatic  medication,  which  has  also  been 
described  under  the  name  of  "  the  medication  of  indications." 

The  Curative  Treatment,  or,  rather,  the  Management  of  Enteric 
Fever  falls  under  certain  convenient  headings,  such  as — Hygiene, 
Diet,  Stimulants,  Antiseptic  Drugs,  Antipyretic  Treatment,  Treat- 
ment of  Complications  and  Sequelae,  Management  in  Conva- 
lescence. 

a  Opera  Omina.     Eomae.     1696.     Ed.  Sext.     Lugduni.     1704.     Page  54. 
b  Le  Bulletin  Medical.    Paris.     Feb.  8,  1889;  and  Sajous'  Annual  of  the 
Universal  Medical  Sciences.     1889.    Vol.  I.,  page  H-55. 


436  ENTERIC    FEVER. 

I.  Hygiene. — The  patient  should  take  to  bed,  as  soon  as  possible 
after  symptoms  show  themselves,  in  a  large,  airy,  quiet,  well- warmed 
and  well-ventilated  room.  Irreparable  mischief  is  done  by  men 
struggling  against  their  illness  day  aftejr  day,  trying  to  "  walk  it  off." 
In  the  Franco-German  war  of  1870-71,  railroad  travelling  espe- 
cially was  proved  to  exert  a  very  prostrating  influence  on  enteric 
fever  patients.  Physicians,  who  should  know  better,  when  they 
are  themselves  attacked  by  this  disease,  are  wont  to  fight  against  it 
and  refuse  to  admit  that  they  are  sick.  Liebermeister  a  has  known 
jDhysicians  to  make  calls  during  the  morning,  when  the  evening 
before  they  had  themselves  seen  that  their  own  temperature  was 
104°  F.  in  the  axilla. 

Not  only  should  the  patient  take  to  bed  as  early  as  possible,  but 
he  should  not  be  allowed  to  sit  up  again  until  the  evening  tempera- 
ture has  been  perfectly  normal  for  from  three  to  six  days  at  least. 
The  hygiene  of  the  sick  room  has  been  discussed  at  pages  44  and 
49,  and  it  only  remains  to  emphasise  the  necessity  for  free  ventila- 
tion. Even  in  winter,  a  window  should  be  kept  open  during  a 
great  part  of  the  twenty-four  hours,  at  all  events  in  the  adjoining 
room  to  that  occupied  by  the  patient.  "  Even  a  strong  draught 
of  air,  for  a  time,  is  harmless,"  for,  adds  Liebermeister,b  "  a  patient 
with  a  high  fever  temperature  cannot  take  cold." 

Attention  to  personal  hygiene  is  of  the  first  importance  in  enteric 
fever.  The  bed  and  body-linen  should  be  changed  as  often  as  they 
are  soiled.  The  body  of  the  patient  should  be  kept  scrupulously 
clean.  The  whole  surface  should  be  carefully  sponged  with  vinegar 
(1  part)  and  tepid  water  (3  parts)  several  times  a  day.  Particular 
care  should  be  paid  to  the  state  of  the  teeth.  A  good  antiseptic 
and  detergent  tooth-paste  is  the  following  : — 

~fy  Pulv.  Saponis  Duri,  gr.  60 ; 

Acid.  Carbolic.  Purissimi  Liquefacti,  5  ss  ; 
Olei  Eucalypti,  Si ; 
Cretse  Prascipitata?,  ad  §i. 
M.  ft.  dentifricium. 

a  Von  Ziemssen's  Cyclop,  of  the  Pract.  of  Med.     Vol.  I.,  page  229.     1875. 
b  Loc.  cit.    Page  231. 


ENTERIC   FEVER.  437 

Should  erythema  show  over  the  nates,  or  sacrum,  or  great 
trochanters,  the  affected  part  should  be  relieved  of  pressure  by  a 
water-cushion  or  an  air-cushion,  and,  as  a  routine  practice  in  all 
cases,  the  surface  should  be  gently  sponged  with  spirit  of  camphor. 
In  this  way,  and  by  paying  attention  to  cleanliness,  the  occurrence 
of  bed-sores  may  be  averted. 

II.  Diet. — The  dietetic  treatment  of  enteric  fever  is  of  the  first 
importance.  There  can  be  little  doubt  that  many  patients  are  over- 
fed rather  than  under-fed  in  this  fever,  with  the  result  that  symptoms 
are  aggravated,  and  diarrhcea  in  particular  is  increased.  Let  us 
reflect  for  a  moment  on  the  diseased  state  of  a  not  inconsiderable 
portion  of  the  digestive  tract,  and  it  will  at  once  be  evident  that  no 
solid  food  is  admissible  even  if  the  patient  did  not  turn  from  it  with 
loathing.  But,  further,  the  powers  of  digestion  are  seriously  im- 
paired, and  the  assimilation  of  food  is  well-nigh  at  a  stand  still.  Our 
object,  in  the  face  of  such  conditions,  should  be  to  give  the  patient 
just  so  much  nutriment  as  will  keep  him  alive  and  enable  him  to 
combat  the  disease  which  is  making  such  inroads  on  his  strength. 

To  secure  these  ends,  the  food  should  be  liquid,  very  nourishing, 
easily  assimilable,  and  exhibited  in  moderate  quantities  at  rather 
short  intervals. 

Von  Ziemssen,  in  his  lectures  on  the  treatment  of  enteric  fever, 
points  out  that  no  pure  albuminous  food  and  still  less  fatty  food  should 
be  given.  Frequent  change  and  variety  of  flavour  and  consistence 
of  food  is  desirable.  Starch,  dextrin,  and  sugar  may  be  exhibited. 
Milk  is  the  most  complete  mixture  of  albumen,  fat,  and  carbo- 
hydrates, and  is  an  excellent  food  in  enteric  fever.  Von  Ziemssen 
does  not  give  more  than  one  pint  as  a  rule  in  24  hours.  Freshly 
expressed  meat  juice,  consisting  of  serum,  lymph,  and  blood,  forms 
an  acceptable  and  highly  digestible  food.  Frozen  meat-juice  is  also 
well  borne.  If  eggs  are  given  in  clear  meat  broths,  not  more  than 
three  should  be  administered  during  24  hours.  Jellies  prepared 
from  fresh  calves'  feet  with  white  wine,  are  refreshing  and  grateful. 

According  to  Stromeyer,  the  best  thing  to  give  to  enteric  fever 
patients  is  oaten  grits,  cooked  for  three  hours,  and  given  without 
sugar  (Liebermeister). 


438  ENTERIC    FEVEE. 

The  nearest  approach  to  an  ideal  food  for  a  fever  patient  is  milk. 
In  making  this  statement  I  do  not  wish  to  be  misunderstood. 
There  are  some  patients  who  cannot  tolerate  a  milk  diet.  In  other 
cases,  patients  are,  as  it  were,  poisoned  with  milk  given  in  excessive 
quantities.  Here,  as  in  all  other  things,  we  must  judge  each  case  on 
its  own  merits.  The  fact  remains  that  in  an  overwhelming  majority 
of  instances,  a  milk  diet  is  the  best  and  safest  for  a  fever  patient. 

It  is  scarcely  ever  necessary  to  exceed  the  amount  of  one  quart 
of  milk  in  the  24  hours — that  is,  40  fluid  ounces.  This  quantity 
should  be  given  in  divided  doses  at  regular  intervals  of  one, 
two,  or  three  hours,  either  plain,  or,  preferably,  mixed  with 
warm  water.  If  it  passes  through  the  bowels  in  the  form  of 
lumpy,  undigested  curd,  it  should  be  peptonised,  with  liquor  pancre- 
aticus,  or  Fairchild's  zymine  peptonising  powders.  Or,  it  may  be 
boiled  and  mixed  with  lime-water  in  the  proportion  of  three  parts 
of  milk  to  one  part  of  lime-water.  The  "  liquor  calcis  saccharatus'" 
of  the  Pharmacopoeia  maybe  substituted  for  the  lime-water  in  pro- 
portionate parts,  the  lime-water  containing  half  a  grain  of  CaO  in 
the  ounce,  whereas  the  saccharated  solution  contains  7*11  grains. 
Four  ounces  of  milk  for  a  meal  would  give  10  feedings  a  day,  at 
intervals  of  nearly  2i  hours.  Some  of  the  milk,  however,  may  be 
given  in  freshly-made  tea  in  the  morning,  and  some  of  it  may  be 
given  as  junket,  or  rennet,  or  in  the  form  of  custard,  or  blanc- 
mange (made  with  isinglass  and  milk),  or  cream.  In  the  earlier 
stages  of  the  fever,  the  feeding  should  be  chiefly  by  day ;  afterwards, 
the  meals  must  be  given  by  night  as  well  as  by  day,  unless  the 
patient  is  in  a  wholesome  sleep  (not  somnolence  or  coma). 

Besides  milk,  animal  broths  may  be  allowed  to  the  extent  of 
one  pint  in  the  24  hours.  Four  such  broths  may  be  mentioned — 
beef -tea,  chicken  broth,  or  chicken  jelly,  veal  broth,  and  mutton 
broth.  Of  these,  the  first  and  last  are  laxative,  and,  therefore, 
should  not  be  given  when  diarrhoea  is  present.  Beef-tea  is  parti- 
cularly valuable  because  of  its  stimulating  power,  especially  upon 
the  heart.  It  may  be  flavoured  with  a  little  tomato  juice  or  a  stick 
of  celery,  I  have  often  found  it  a  good  plan  to  mix  beef -tea  and 
chicken  jelly  in  equal  parts,  when  a  patient  tired  of  either  singly. 


ENTERIC    FEVER.  439 

Also,  towards  convalescence,  tapioca,  sago,  or  well-boiled  rice,  may 
be  added  to  the  broth  in  moderate  quantities.  The  laxative  effect 
of  broth  is  lessened  by  adding  a  little  isinglass  (gelatin)  or  arrow- 
root to  it. 

In  very  prostrate  conditions,  Liebig's  beef- tea,  prepared  by 
macerating  lean  meat,  chopped  very  fine,  with  hydrochloric  acid, 
and  a  little  salt,  will  be  found  a  valuable  food.  A  receipt  for  thifl 
preparation  will  be  found  at  page  513  of  Dr.  F.  W.  Pavy's  "  Treatise 
on  Food  and  Dietetics  "  (1874). 

If  it  is  desired  to  give  stimulants  and  food  together,  a  tea- 
spoonful  of  brandy  or  whisky  may  be  added  to  each  teacupful 
of  warmed  milk,  or  the  excellent  egg  and  brandy  mixture  of  the 
Pharmacopoeia  (mistura  spiritus  vini  gallici)  may  be  prescribed. 

As  a  beverage,  pure  water  may  be  taken  without  stint.  All 
through  the  fever  cold  water  is  the  most  grateful  drink.  When 
the  tongue  is  furred  and  dry,  a  teaspoonful  of  glycerine  or  of 
glycerine  of  borax  may  be  added  to  each  tumblerful  of  drinking 
water  ;  or  the  tongue,  gums,  and  mouth  generally  may  occasionally 
be  painted  with  a  linctus  like  the  following,  which  will  prevent 
or  check  the  formation  of  sordes  : — 

1^     Potassii  chloratis,  gr.  30  ; 
Acid.  Borici,  gr.  20  ; 
Glycerini, 

Succi  Limonis,  aa  §ss. 
Fiat  Linctus. 

Other  diet  drinks  or  tisanes,  for  occasional  use  according  to 
circumstances  are  : — Toast  and  water,  barley-water  flavoured  with 
oil  of  lemon  (lemon  rind),  red  or  black  currant  jelly  in  hot  or  cold 
water — very  grateful  where  sore  throat  is  present,  or  strained 
tamarind  tea  (Hilton  Fagge).  Ice  may  be  sucked,  but  it  some- 
times parches  the  mouth  and  lips  rather  than  affords  relief.  Von 
Ziemssen  recommends  thin  oat-  and  barley-water,  the  flavour  being 
varied  by  the  addition  of  sugar,  cinnamon,  wine,  &c. 

Seltzer  water,  or  other  similar  mineral  waters,  the  mineral  acids 
in  water,  with  or  without  sugar,  thin  milk  of  almonds  (mistura 
amygdalae),  and  a  thin  decoction  of  parched  rice  (especially  where 


440  ENTEKIC    FEVEE. 

there  is  a  good  deal  of  diarrhoea)  are  added  to  the  diet  drinks  by 
Liebermeister.  In  advanced  stages  of  this  fever,  or  where  tympa- 
nites is  a  troublesome  symptom,  aerated  waters  are  contra-indicated. 

III.  Stimulants. — The  rules  already  laid  down  for  the  admi- 
nistration of  alcohol  in  acute  disease  apply  in  general  to  enteric 
fever  (see  pages  58  and  310).  On  the  whole,  stimulants  are  not 
so  much  required  in  enteric  fever  as  in  typhus,  because  the  patients 
are  often  younger,  and  the  heart  is  less  affected.  But  it  is  often 
necessary  to  prescribe  them — never  as  a  matter  of  routine,  but  in 
definite  doses  and  at  specified  intervals,  just  like  any  other  medicine. 
Failure  of  the  circulation,  pulmonary  congestion,  and  general 
depression  are  the  indications  for  the  giving  of  stimulants.  Brandy 
in  milk,  or  diluted  and  sweetened,  agrees  best  with  young  children. 
Burgundy,  port,  and  good  claret  suit  adults,  and  old  people  are  bene- 
fited by  whisky,  brandy,  or  champagne.  The  presence  of  albuminous 
urine,  and,  still  more,  of  other  evidences  of  nephritis,  is  an  indica- 
tion for  the  very  cautious  administration  of  alcoholic  stimulants. 

IV.  Antiseptic  Drugs. — As  yet,  we  possess  no  specific  for  the 
prevention  or  cure  of  enteric  fever.  At  the  same  time,  certain 
drugs  appear  to  have  a  distinctly  beneficial  effect  in  the  disease 
where  judiciously  and  properly  administered. 

Passing  by  the  treatment  by  means  of  iodide  of  potassium,  ad- 
vocated by  Sauer  in  1840,  and  revived  by  Magonty  in  1859,  and 
von  Willebrand  in  1866 — the  last-named  using  a  solution  of  one 
part  iodine,  two  parts  iodide  of  potassium,  and  ten  parts  water, 
giving  three  or  four  drops  in  a  glass  of  Avater  every  two  hours,  we 
find  calomel  in  large,  or  small  and  repeated,  doses  recommended  by 
many  distinguished  authorities,  such  as  Lesser  (1830),  Traube, 
Wunderlich,  Liebermeister,  and  von  Ziemssen  in  Germany ;  and 
Bouchard  in  France.  Liebermeister  has  given  this  remedy,  with 
but  few  exceptions,  to  every  case  of  the  fever  (about  800  in  number) 
admitted  before  the  ninth  day  of  the  disease,  in  three  or  four  eight- 
grain  doses  during  the  first  twenty-four  hours  of  treatment.  In  his 
hands,  the  death-rate  fell  from  18*3  per  cent,  among  377  patients 
treated  non-specifically  to  11*7  per  cent,  among  223  patients  put  on 
the  calomel  treatment.     Further,  he  found  that  the  use  of  calomel 


ENTERIC   PBVBK.  441 

materially  shortened  the  duration  of  the  disease  and  diminished  its 
intensity.  Bouchard  considers  that  general  antisepsis  is  secured 
by  mercurial  preparations.  During  four  days,  only  at  the  begin- 
ning of  the  fever,  the  patient  should  take  daily  twenty  pills  of  2 
centigrammes  of  calomel  (6  grains  in  all). 

On  November  16,  1883,  I  reported  to  the  Medical  Section  of 
the  Academy  of  Medicine  in  Ireland  the  case  of  a  man,  aged 
twenty,  a  grocer's  assistant,  who  was  admitted  into  Cork-street 
Fever  Hospital  on  September  28,  1883,  on  the  eighth  day  of  a 
severe  attack  of  enteric  fever.  The  fever  ran  a  course  of  four 
weeks,  and  was  characterised  by  a  succession  of  high  temperatures 
during  the  first  twenty  days,  ataxic  symptoms,  obstinate  constipa- 
tion, hypostatic  congestion  of  the  lungs,  and  right  basic  pneumonia. 
Furthermore,  treatment  of  a  decidedly  active  kind  Avas  employed, 
and  apparently  with  marked  benefit  to  the  patient.  On  five  sepa- 
rate occasions  twenty  grains  of  quinine  were  given  as  an  antipy- 
retic in  two  quickly  succeeding  doses  of  ten  grains  each  ;  twice  the 
wet  "  pack"  was  employed  for  two  hours  at  a  time  to  control  the 
pyrexia ;  and  on  three  occasions,  at  intervals  of  forty-eight  hours, 
ten-grain  doses  of  calomel,  guarded  with  a  grain  of  opium,  were 
administered  as  an  antiseptic  aperient. 

The  administration  of  calomel  in  large  doses  in  enteric  fever  is 
nothing  new,  and  is  much  thought  of  in  Germany  at  all  events.3, 
"-After  the  accurate  observations  of  Wunderlich,"  says  Niemeyer,b 
"  we  can  scarcely  doubt  that  by  this  remedy  we  may,  in  some  few 
cases,  cut  short  the  disease  (according  to  Wunderlich  one  or  two 
five-grain  doses  are  enough),  and  that  in  the  great  majority  of 
cases  where  this  remedy  is  given  during  the  first  week,  and  before 
the  occurrence  of  much  diarrhoea,  the  course  of  the  disease  is 
rendered  milder  and  shorter.  The  experience  of  Pfeufer's  clinic, 
as  well  as  my  own,  perfectly  agrees  with  Wunderlich's.  We  shall 
not  attempt  to  say  whether  the  calomel  has  a  favourable  influence 
on  the  typhous  intestinal  disease  by  opposing  the  sloughing  and 

n  Cf.  Von  Ziemssen's  Cyclopaedia  of  the  Practice  of  Medicine.     Vol.  I.,  page 
200.     "Acute  Infectious  Diseases." 
bLoc.cit.     P. -647. 


442  ENTEEIC   FEVER. 

ulceration,  and  whether,  consequently,  we  can  expect  benefit  from 
it  only  in  the  first  weeks  of  the  disease,  when  these  changes  have 
not  yet  taken  place." 

Niemeyer's  observations  have  recently  gained  additional  weight 
in  an  unexpected  and  interesting  manner.  Dr.  Wassiljeff  some 
years  ago  studied  experimentally,  in  Hoppe-Seyler's  laboratory, 
the  influence  of  calomel  on  fermentation  and  bacteria.  He  found 
that  the  presence  of  one  part  of  calomel  in  from  twenty  to  one 
hundred  parts  of  fibrin  or  fat,  did  not  interfere  with  the  action  of 
the  unorganised  ferments  of  the  saliva,  gastric  juice,  and  pancreatic 
juice ;  but  the  calomel  did  prevent  the  formation  of  certain  decom- 
position products — as  indol,  phenol,  skatol,  creasote,  and  hydrogen 
sulphide.  The  calomel  also  prevented  butyric  acid  fermentation. 
The  action  of  calomel  upon  bacteria  or  micrococci  was  next  studied, 
according  to  the  Buchholtz-Wernick  method.  It  was  ascertained 
that  the  drug  destroyed  these  organisms  and  prevented  the  appear- 
ance of  new  ones.  From  this  it  seems  that  calomel  destroys 
organised  ferments,  but  is  without  effect  upon  the  unorganised  ones. 
So  far,  all  the  experiments  had  been  outside  the  body.  Now,  ex- 
periments were  made  on  three  dogs.  They  were  given  one  grain 
of  calomel  each,  and  after  some  hours  were  killed.  The  intestines 
were  ligated  in  the  upper  part  of  the  duodenum  and  in  the  lower 
part  of  the  colon,  and  the  entire  contents  were  carefully  examined. 
In  no  case  could  the  putrefactive  products,  indol,  skatol,  hydrogen 
sulphide,  &c,  be  detected.  It  would  seem  from  this  that  much  of 
the  good  which  calomel  is  known  to  accomplish  in  various  intestinal 
troubles  is  due  to  its  aseptic  properties.3. 

Remembering,  then,  these  aseptic  or  antiseptic  properties  of 
calomel,  I  felt  no  small  degree  of  confidence  in  prescribing  it  in 
combination  with  opium — itself  an  antiseptic — in  a  case  where 
persistent,  constipation  during  an  attack  of  enteric  fever,  charac- 
terised  by  very  high  temperatures,  was  only  too  likely  to  lead  to 
the  formation  of  decomposition  products  in  a  diseased  intestine. 

Other  antiseptics,  among  very  many  which  have  been  recom- 

a  The  Physician  and  Surgeon,  and  Dublin  Journal  of  Medical  Science  for 
October,  1883.     Page  327. 


F.XTKKK      FKVKl;.  443 

mended,  are — arsenic,  by  Dr.  Frederick  Kirkpatrick  a  ;  antimony, 
by  Surgeon-Major  Edward  Lawrie,b  Residency  Sm*geon,  Hydera- 
bad ;  /3-naphthol,  by  Prof.  Boucbard,  of  Paris ;  hydronaphthol,  by 
Michell  Clarke ; c  carbolic  acid,  by  Dr.  F.  Sidney  Gramshaw,d 
of  Easingwold,  Yorkshire ;  tbe  sulphites,  strongly  recommended 
by  Professor  Polli,  of  Milan  ;  and,  above  all,  turpentine — an  old- 
fashioned  and  most  valuable  remedy,  free  chlorine,  and  quinine. 

Arsenic  usually  controls  diarrhoea ;  it  is  a  heart-medicine,  and 
helps  the  patient  to  combat  the  adynamia  of  the  fever.  It  may 
be  given  with  acids  in  the  form  of  the  hydrochloric  solution — 
1  to  5  minims  for  a  dose  thrice  daily. 

Surgeon-Major  Lawrie  gives  the  antimony  as  recommended  by 
Dr.  Kent  Spender,e  of  Bath,  in  frequently  repeated  small  doses — 
one-sixteenth  of  a  grain  of  tartar  emetic  every  hour  or  every  two 
hours.  He  finds  that  it  cuts  enteric  fever  short  "  with  such 
certainty  that  it  almost  appears  doubtful  whether  the  lesion  of 
typhoid  is  specific,  or  is  not  rather  incidental  or  adventitious." 

Professor  Bouchard f  uses  and  recommends  /3-naphthol,  reduced 
to  a  fine  powder  and  mixed  with  salicylate  of  bismuth.  One 
hundred  and  fifty  grains  of  /3-naphthol  are  mixed  with  75  grains 
of  salicylate  of  bismuth,  and  this  is  divided  into  thirty  powders. 
From  three  to  twelve  of  these  are  given  in  the  24  hours, 
enclosed  in  a  wafer,  and  swallowed  with  the  food.  The  /3-naph- 
thol, insoluble  in  water,  glycerine,  or  alcohol,  reaches  the  intestine 
in  consequence,  and  there  acts  as  a  powerful  disinfectant,  certainly 
deodorising  the  evacuations  (J.  Burney  Yeo). 

Dr.  Leroux  leaves  out  the  bismuth  from  this  combination  when 
diarrhoea  is  not  urgent ;  and  if,  on  the  contrary,  there  is  constipa- 
tion, he  substitutes  for  it  salicylate  of  magnesium  until  the  bowels 
are  free.     It  was  Huchard,  of  Paris,  who  first  recommended  this 

a  Dull.  Joum.  of  Med.  Science.     Vol.  XCL,  page  420.     1891. 
b  Report  oil  the   Civil  Medical  Department  of  His   Highness   the  Nizam's 
Government  for  1888  (1279,  Fasli).     Hyderabad.     1889.     Page  18. 
0  The  Practitioner,  December,  1888,  and  Journal  de  Med.  et  de  Chir. 
d  The  Lancet,  June,  23,  1888. 
e  The  Practitioner,  March,  1885. 
f  Therapeutique  des  Maladies  Infcctueuses.     Paris.     1889. 


444  ENTERIC    FEVER. 

salt  instead  of  bismuth  salicylate.  The  drug  acts  both  as  an  anti- 
pyretic and  as  an  antiseptic  in  doses  of  50  to  100  grains  daily. 
Its  laxative  action  is  not  great,  so  that  its  use  is  not  contra- 
indicated  in  cases  where  diarrhoea  is  copious.  The  formula  of  the 
salt  is  as  follows  : — 

(c6H4^C00^)2Mg+4H20. 

It  contains  74*6  per  cent,  of  salicylic  acid  (Pharra.  Post,  March 
18,  1888). 

Dr.  J.  Michell  Clarke,  of  Bristol,  recommends  hydronaphthol 
in  the  treatment  of  enteric  fever.  It  is  a  grayish-white  crystal- 
line powder,  with  a  slight  iodine  odour,  of  somewhat  indefinite 
composition,  but  yielding  on  repeated  crystallisation  a  substance 
corresponding  to  /3-naphthol.  Dr.  Clarke  finds  that  it  agrees  with 
patients  who  are  on  an  exclusively  milk  diet,  although  with  other 
diets  it  is  very  apt  to  disagree.  He  prescribes  2  or  3  grains  in 
gelatin  capsules,  or  simply  suspended  in  milk,  or  in  a  keratin- 
coated  pill.  This  dose  may  be  given,  when  diarrhoea  is  present, 
every  two  hours  for  the  first  three  to  six  doses ;  afterwards  every 
three  or  four  hours.  For  children  under  one  year  the  dose  is  half 
a  grain,  older  children  may  take  half  a  grain  to  one  grain  every 
hour,  every  two  hours,  or  less  often. 

Carbolic  acid  is  ordered  in  a  mixture,  of  which  this  is  the 
formula : — 

fy     Acid.  Carbol.  Purissimi  (Calvert)  Liquefacti,  min.  xii ; 
Tinctura?  Iodi.  (B.  P.),  min.  xvi ; 
Tincturoe  Aurantii  Cort.,  3iss  ; 
Syrupi  Simplicis,  5iii ; 
Aqua?,  ad  Sviii- 

Dose  :  One  ounce  every  four  hours  for  the  first  fortnight,  or 
until  the  urgent  symptoms  yield,  and  then  three  times  a  day. 

If  vomiting  is  excited,  the  dose  of  carbolic  acid  should  be  reduced, 
and  a  small  quantity  of  dilute  nitro -hydrochloric  acid  should  be 
added  to  the  mixture.  Dr.  Gramshavv  rarely  noted  carboluria  as  a 
result  of  the  treatment,  which  causes  diarrhoea  to  cease. 

The  sulphites,  recommended  by  Polli,  seemed  to  Murchison  to 
excite  diarrhoea  in  some  cases,  and  not  to  be  of  much  use.    Twenty 


ENTERIC    FEVEK.  445 

grains  of  sulphite  of  sodium, or  from  1  to2 drachms  of  sulphurous  acid, 
largely  diluted,  may  be  given  every  four  hours.  Dr.  Wilks,  of  Asli- 
ford,  in  a  paper  published  in  the  Brit.  Med.  Journal,  so  long  ago  as 
1870,  claimed  for  sulphurous  acid  that  it  arrested  the  further  develop- 
ment of  the  poison  of  enteric  fever,  and  was,  in  fact,  an  antidote. 

Turpentine  is  an  excellent  diffusible  stimulant,  and  an  antiseptic 
of  great  value.  It  relieves  chest  complications,  controls  diarrhoea, 
checks  meteorism,  and  stays  intestinal  haemorrhage.  To  secure 
the  last-named  object,  it  may  be  prescribed  Avith  ergot,  according 
to  the  formula  already  given  at  page  124.  In  other  cases,  and  for 
other  purposes,  5  to  10,  15  or  20,  minims  of  rectified  spirit  of  tur- 
pentine may  be  given  every  second  or  third  hour  in  capsule,  or  rperle, 
or  mixture.  Should  albuminuria,  or  nephritis  be  present,  turpen- 
tine must  be  administered  with  caution. 

Years  ago  this  remedy  was  given  with  good  results  in  adynamic 
fevers  in  the  Meath  Hospital  in  the  form  of  "  Turpentine  Punch." 
It  was  introduced  by  Mr.  Parr,  the  apothecary  to  the  hospital. 

A  good  way  of  prescribing  it  is  with  spirit  of  nitrous  ether  as 
follows : — 

fy    Spt.  Terebinth.  Rectificati  (or  Olei  Terebinth.),  3ii  ; 
Spt.  iEtheris  Nitrosi,  3i ; 
Spt.  Chloroformi,  5ii  5 
Misturae  Amygdalae,  ad  gvi. 
Misce.  Ft.  mist.     Signa  :  "  Half  an  ounce  for  a  dose." 

The   Confection   of  Turpentine  of   the  British  Pharmacopoeia 
may  be  prescribed  in  60  grain  doses  with  peppermint  water ;  or 
the  official  oil  of  turpentine  emulsified  with  yolk  of  egg  may  be 
given  with  spirit  of  chloroform  and  peppermint  water.     According 
to  Dr.  W.  Whitla,a  Dr.  E.  Nelson  prescribes  the  drug  thus : — 
B  Olei  Terebinth,  3iii ; 
iEtheris,  3i"  '■> 
Syrupi  Tolutani,  ^i; 
Mucilaginis  Acaciae,  |i; 
Aquae  Menthae  Piperitae,  ad  ^viii. 
M.  ft.  mist.     Signa ;  "  Half  an  ounce  for  a  dose." 

a  Elements  of  Tharmacy,  Materia  Medica,  and  Therapeutics.  By  William 
Whitla,  M.D.,  J.P.     1889.     Page  520. 


446  ENTERIC    FEVER. 

Professor  Horatio  C.  Wood,  of  New  York,  bears  eloquent  testi- 
mony to  the  usefulness  of  oil  of  turpentine  in  enteric  fever.  He 
gives  his  uncle,  Dr.  George  B.  Wood,  the  credit  of  introducing 
this  drug  into  the  treatment  of  enteric  fever.  Professor  Wood 
adopts  the  following  formula : — 

r^  Olei  caryophylli,  min.  vi ; 
Olei  Terebiuthinaa,  5iss ; 
Glycerin  i, 

Mucilaginis  acacia?,  aa,  $ss  ; 
Syrupi  et  aquae,  aa  ad  giii. 

M.  ft.  mist.     Signa :  "  A  dessertspoonful  to  be  given  every 
two  hours  during  the  day." 

In  intestinal  haemorrhage,  20  minim  doses  of  oil  of  tui'pentine 
every  hour  or  every  second  hour  is  an  efficient  remedy. 

Both  Sir  Thomas  Watson  and  Murchison,  and  quite  recently 
Burney  Yeo,a  highly  recommend  free  chlorine  as  a  useful  anti- 
septic in  this  fever. 

The  liquor  chlori  of  the  Pharmacopoeia  may  be  prescribed  in  20 
minim  doses  with  the  mineral  acids,  or  we  may  prepare  a  fresh 
solution  of  chlorine  gas  as  recommended  by  Dr.  Yeo. 

"  Into  a  twelve-ounce  bottle  put  thirty  grains  of  powdered 
potassic  chlorate,  and  pour  on  it  40  minims  of  strong  hydrochloric 
acid.  Chlorine  gas  is  at  once  rapidly  liberated.  Fit  a  cork  into 
the  mouth  of  the  bottle,  and  keep  it  closed  until  it  has  become 
filled  with  the  greenish  yellow  gas.  Then  pour  water  into  the 
bottle,  little  by  little,  closing  the  bottle,  and  well  shaking  at  each 
addition  until  the  bottle  is  filled."  .  .  .  "To  twelve  ounces  of 
this  solution  for  an  adult,  I  add  twenty-four  or  thirty-six  grains  of 
quinine,  and  an  ounce  of  syrup  of  orange  peel,  and  I  give  an  ounce 
every  two,  three,  or  four  hours,  according  to  the  severity  of  the 
case." 

Dr.  Yeo  says  that  this  is  pleasanter  to  take  than  the  official 
liquor  chlori.  The  tongue  cleans  quickly,  and  the  foetor  of  the 
evacuations  subsides.  Dr.  Yeo  thinks  that  we  obtain  not  only  an 
intestinal  but  also  a  general  antisepsis  by  this  treatment. 

a  Treatment  of  Typhoid  Fever.    London.     1891,    Page  29. 


EMEIilC    FEVEK.  447 

Ebertli,  in  experimenting  with  the  Bacillus  typhosus,  found  that 
quinine  checked  its  culture.  This  observation  enhanced  the  opinion 
long  entertained  that  this  substance  was  not  only  an  antipyretic  but 
an  antiseptic  in  enteric  fever.  W.  Vogt,  of  Berne,  Iiebermeister, 
of  Tubingen,  Bouchard,  of  Paris,  and  Clement  Cleveland,  of  New 
York,  all  recommend  that  the  system  should  be  rapidly  saturated 
with  quinine  early  in  the  fever. 

To  adults  Liebermeister  usually  gives  from  22^  to  45  grains  of 
the  sulphate  or  hydrochlorate  of  quinine,  in  powders  of  1\  grains 
each,  every  ten  minutes.  He  does  not  repeat  these  large  doses  for 
48  hours.     Quinism  is  genei-ally  produced  to  an  extreme  degree. 

Bouchard  gives  30  grains  every  third  evening,  in  four  equal 
doses  of  7^  grains  each  every  half  hour  during  the  first  fortnight. 
In  the  third  week,  the  30  grains  are  reduced  to  22^  grains,  and  in 
the  fourth  week  to  15  grains  every  third  day. 

Dr.  Clement  Cleveland  a  gives  from  five  to  ten  grain  doses  every 
fifteen  minutes  for  two  hours.  At  other  times  he  gives  from  5  to 
10  grains  every  two  or  three  hours.  When  this  treatment  agrees, 
the  patients  seemed  to  him  to  recover  more  quickly  and  perfectly, 
and  Avith  fewer  sequehe.  He  Avas  also  impressed  with  the  fact  that 
the  death-rate  is  much  loAver  Avith  the  quinine  treatment  than  with 
the  expectant  plan. 

Professor  Grancher,  of  Paris,  gives  a  child,  aged  five,  from  15  to 
22|-  grains,  divided  into  three  doses,  e\Tery  half  hour  at  about  5  or 
6  p.m.  The  child  usually  sleeps  after  these  large  doses.  Dr. 
Grancher  believTes  that  quinine  has  a  specific  antiseptic  action  in 
enteric  fever. 

Burney  Yeo,  as  already  mentioned,  gives  moderate  doses  in  com- 
bination with  chlorine. 

The  foregoing  by  no  means  exhausts  the  list  of  antiseptics 
recommended  in  the  treatment  of  enteric  fever.  Dr.  Burney  Yeo 
quotes  the  folloAving  additional  remedies  : — 

Mr.  Kesteven,  of  Brisbane,  in  the  Practitioner  of  May,  1885,  and 
of  April,  1887,  wrote  in  Avarm  praise  of  the  value  of  oil  of 
eucalyptus  in  this  disease.  He  gave  it  in  220  cases,  many  of  whom 
a  Neic  Turk  Medical  Record.    Nov.  20th,  1886. 


448  ENTERIC    FEVER. 

had  a  "  bad  start,"  and  lie  had  only  four  deaths.  The  dose  employed 
was  from  5  to  10  minims,  in  emulsion  with  mucilage  every  four 
hours.  He  combined  with  each  dose  half  a  drachm  of  sal  volatile, 
half  a  drachm  of  spirit  of  chloroform,  and  half  a  drachm  of  glycerine. 

Dr.  Janeway,  of  New  York,  highly  recommends  camphor,  not 
only  as  an  excellent  antiseptic,  but  also  as  a  cardiac  stimulant.  In 
the  Dublin  Journal  of  Medical  Science  for  November,  1879  (Vol. 
LXVIII,  page  411),  Mr.  George  B.  White,  F.R.C.S.I.,  reported  a 
case  of  enteric  fever  of  nine  weeks'  duration  complicated  with 
acute  cerebral  symptoms,  phlegmasia  dolens  of  the  left  leg,  and 
rigors,  in  which  a  very  large  dose  of  camphor  (more  than  40  grains), 
given  by  mistake,  was  followed  almost  immediately  by  good  results. 
In  dispensing  a  mixture  ordered  to  be  compounded  with  camphor 
water,  spirit  of  camphor  was  substituted,  and  the  patient,  a  lady 
aged  21,  swallowed  40  grains  of  camphor  in  nearly  one  ounce  of 
"rectified  spirit. 

Pe'cholier,  of  Montpellier,  is  an  advocate  for  the  administration 
of  creasote  both  by  the  mouth  and  in  enemata,  while  thymol  has 
been  given  by  Dr.  F.  Henry,  in  doses  of  a  grain  and  a  half,  or  two 
grains,  made  into  a  pill  with  soap,  every  six  hours.  The  Italian 
physician,  Testi,a  has  also  given  thymol  in  150  cases  of  enteric 
fever  with  good  results. 

L.  Wolff,b  in  a  recent  paper,  speaks  highly  of  naphthalin  as  an 
antiseptic  remedy.  His  opinion  is  based  on  its  employment  in  one 
hundred  consecutive  cases.  This  remedy  was  proposed  by  L. 
Natanson  in  a  communication,  entitled  "  La  Naphtaline  dans 
la  Fievre  Typholde." c 

Edgar  Hirtz  prescribes  salol,  in  combination  with  salicylate  of 
bismuth,  in  doses  of  60  grains  (4  grammes)  a  day.  It  appears  to 
act  like  naphthol.  The  stools  lose  their  foetid  odour,  the  tongue 
cleans  rapidly.  It  is  valuable  from  two  points  of  view :  it  effects 
first  an  intestinal  antisepsis,  next  an  urinary  antisepsis,  for  it  is 

a  Allgem.  Wien.  med.  Zeitung.    No.  9,  page  90.    1889. 

*>  Medical  Nms.     Philadelphia.     1891.     LVIII.,  pages  569-572. 

c  Bulletin  de  la  Soc.  de  Med.  prat,  de  Paris.    1891.     Pages  161-163. 


ENTERIC    FEVER.  449 

broken  up  in  the  system  into  salicylic  acid  and  carbolic  acid,  which 
are  eliminated  in  the  urine."' 

A  combination  of  /3-naphthol  with  salicylic  acid,  known  as  the 
salicylate  of  naphthol,  or  briefly  betol,  has  been  in  use  for  some 
time  as  a  substitute  for  /3-naphthol.  The  composition  of  this  pre- 
paration is,  however,  not  constant,  and  it  sometimes  injures  diseased 
kidneys. 

MM.  Yvon  and  Berlioz,  of  Paris,  have  recently  drawn  attention5 
to  the  value  as  an  intestinal  antiseptic  of  benzoate  of  /3-naphthol, 
or,  as  they  term  it,  benzonaphthol.  It  is  obtained  by  acting  on 
/3-naphthol  with  benzoyl  chloride.  When  purified  by  repeated  solu- 
tion in  and  crystallisation  from  boiling  alcohol,  and,  finally,  by 
means  of  a  dilute  solution  of  caustic  soda,  it  appears  as  a  white 
crystalline  powder  without  taste  or  smell.  Its  formula  is  C10H7O 
(C7H50).  When  introduced  into  the  intestinal  canal  it  breaks  up 
into  /3-naphthol,  which  remains  in  the  intestine,  and  benzoic  acid, 
which  passes  off  in  the  urine  in  combination  with  alkaline  bases,  or 
is  converted  in  greater  or  less  amount  into  alkaline  hippurates. 

Benzonaphthol  should  be  given  in  small  doses  frequently  re- 
peated— 4  to  8  grains  in  wafer  paper,  or  suspended  in  syrup  and 
water  every  three  or  four  hours.  An  adult  may  take  up  to 
5  grammes  (75  grains),  a  child  up  to  2  grammes  (30  grains)  a  day. 

Although  I  have  felt  it  a  duty  to  bring  forward  the  foregoing 
long  list  of  drugs  which  are  now  employed  in  the  treatment  of 
enteric  fever,  I  thoroughly  agree  with  Dr.  Hilton  Fagge  when  he 
says  that  "  at  present  the  most  rational  and  successful  treatment 
of  this,  as  of  most  other  fevers,  is  to  help  the  patient  by  rest,  suit- 
able food,  and  good  nursing ;  to  watch  carefully  and  intelligently, 
and  to  interfere  when  complications  arise  but  not  before." 

In  fact,  the  attitude  of  the  physician  who  is  in  attendance  upon 
a  patient  in  enteric  fever  should  be  that  of  watchful,  intelligent, 
and  armed  expectancy. 

a  La  Pratique  Journali ere  des  ffdpitaux  de  Paris.     1891.     Page  166. 
b  Le  Proyres  Medical,  Nov.  14,  1891,  and  The  Practitioner,  Dec,  1891. 


2    G 


450 


CHAPTER  XL VI. 
Curative   Treatment   of   Enteric  Fever  {Continued). 

Antipybetic  Treatment  :  (1).  The  Water-treatment  (hydrotherapy,  or 
balneotherapy),  cold,  cooi,  and  warm  baths  ;  immersion  treatment  (Dr.  James 
Barr) — Description  of  Apparatus — (2).  Reduction  of  Temperature  by  means 
of  the  Ambient  Air  (de  Souza). — (3).  Antipyretic  Drugs  :  Quinine,  salicin, 
salicylic  acid,  the  salicylates,  salol,  phenazone,  acetanilide,  kairin,  thallin,  digi- 
talis, veratria,  resorcin  or  thymic  acid  with  acetanilide — Hilton  Fagge's  Placebo. 

V.  The  antipyretic  treatment  of  enteric  fever  is  based  on  the 
clinical  experience  that  a  continuous  and  protracted  high  tempe- 
rature inflicts  grave  injury  upon  the  nervous  system,  the  muscular 
tissues,  and  particularly  the  heart.  It  is  not  the  mere  height 
of  the  thermometer  at  a  given  moment  which  is  harmful,  but  a 
temperature  which  is  persistently  above  normal.  A  temperature 
ranging  from  98°  or  100°  at  one  time  of  the  day  to  106°  at 
another  time  will  do  less  harm  than  a  temperature  which  keeps 
continuously  high  at  102°  or  103°.  Another  noteworthy  fact  is 
that  childreu,  as  compared  with  adults,  not  only  become  feverish 
more  easily  and  quickly,  but  also  bear  high  temperatures  much 
better.  Hence,  it  is  not  necessary  to  take  the  same  active  steps  to 
reduce  pyrexia  in  the  very  young  which  we  must  adopt  if  adults 
are  to  be  saved  when  stricken  by  fever. 

(A.)  Far  in  advance  of  all  other  means  for  reducing  temperature 
in  enteric  fever  stands  the  water  treatment.  The  reasons  for  this 
pre-eminence  are  given  in  Cantani's  Address  on  "  Antipyresis,'' 
to  the  Tenth  International  Medical  Congress  at  Berlin.  To  this 
classical  oration  reference  has  already  been  made  at  page  53,  and 
in  the  same  place  the  reader  will  find  a  full  accouut  of  the 
different  ways  in  which  this  method  of  treatment  may  be  carried 
into  effect. 

First  adopted  by  Currie,  of  Liverpool,  in  1787,  the  cold  water 
treatment  of  fever  fell  into  abeyance  for  many  years.     Its  revival 


ENTERIC    FEVER.  451 

was  due  to  Ernst  Brand,a  of  Stettin  (1861)  and  Jiirgensen.b  of 
Kiel  (1866);  and  since  the  publication  of  the  results  obtained  by 
these  writers,  this  method  of  treatment  has  been  widely  adopted  in 
Germany,  France,  America,  Australia,  and  England.  In  1880, 
Dr.  Cayley,  of  the  London  Fever  Hospital,  discussed  the  subject  at 
length  in  the  Croonian  Lectures,  and  in  the  third  edition  of  Mur- 
chison's  "  Treatise  on  the  Continued  Fevers  of  Great  Britain,"  he 
gives  a  full  account  of  his  practical  experience  of  the  cold  bath 
treatment,  both  at  the  London  Fever  Hospital  and  at  the  Middlesex 
Hospital. 

Dr.  Hilton  Fagge c  describes  the  practical  application  of  the 
water  treatment  very  succinctly  as  follows  : — 

"  When  we  have  decided  on  bringing  down  the  temperature, 
there  are  several  ways  of  accomplishing  it.  One  is  to  place  the 
patient  at  once  in  a  cold  bath  of  60°  or  65°  F.  The  shock  may 
sometimes  serve  as  a  useful  stimulus  ;  but  it  is  almost  always  better 
to  use  a  tepid  bath  of  90°  to  85°  F.,  and  rapidly  cool  the  water 
with  lumps  of  ice.  The  temperature  is  best  watched  by  means  of 
a  thermometer  in  recto,  and  it  must  be  remembered  that  it  will 
most  likely  fall  considerably  after  removal  from  the  bath.  Another 
important  precaution  is  to  give  brandy  immediately  after,  or  even 
before,  the  bath,  so  as  to  stimulate  the  heart,  and  further  the 
cutaneous  circulation.  Currie's  original  plan  of  cold  affusion  is 
best  adapted  to  relieving  headache  and  delirium  with  pyrexia  by 
directing  a  douche  upon  the  head.  The  practical  difficulties  of  a 
bath  in  the  case  of  adult  patients,  and  the  serious  disadvantage  of 
lifting  and  moving  them — it  may  be  many  times  in  a  few  hours — 
speak  strongly  for  applying  cold  to  the  surface  as  they  lie  in  bed. 
For  this  purpose  the  '  wet  pack '  has  been  often  used  with  good 
success.  It  is  usually  soothing  and  sedative  as  well  as  antipyretic, 
but  it  is  less  effectual  than  the  bath,  and  sometimes  is  resented. 
Another  plan  is  placing  bladders  of  ice  in  the  axilla  and  over  the 

a  Hydrotherapie  des  Typhus.     Stettin.     1861. 

b  Klinische  Studien  iiber  die  Behandlung  des  Abdominal -typhus  mittelst  des 
Jralten  Wassers.     Leipzig.     1866. 

0  Principles  and  Practice  of  Medicine.  Third  Edition.  1891.  Vol.  L, 
page  172. 


452  ENTERIC   FEVER. 

great  vessels  of  the  neck  and  thighs,  or  fixing  a  c<>il  of  Leiter's 
tubes  in  the  same  regions  and  feeding  them  from  a  receptacle  of 
iced  water  placed  over  the  patient's  bed.  But  in  many — perhaps 
in  most — cases,  the  easiest  and  safest  is  also  the  most  efficient 
method,  namely,  sponging  the  surface  with  cold  water,  or  rubbing 
the  trunk  and  limbs  with  pieces  of  ice,  as  the  patient  lies  on  a 
blanket  with  a  waterproof  sheet  under  it.  Even  when  there  does 
not  appear  any  call  for  active  interference,  sponging  the  face,  arms, 
and  legs  with  cold  water  or  spirit  lotion,  is  grateful  to  the  patients, 
and  is  often  followed  by  tranquil  sleep." 

According  to  Prof.  Paul  Lefort,a  Parisian  physicians  are  now 
practically  unanimous  in  recommending  "  la  Balneotherapie "  in 
enteric  fever.  He  quotes,  as  joining  in  a  chorus  of  approval  of 
this  method  of  treatment,  Bouchard,  Hayem,  Millard,  Chauffard, 
Geiin-Rose,  Juhel-Re'noy,  and  Josias.  Gerin-Rose  advises  that 
the  patients,  in  addition  to  having  baths  at  30°  C.  (86°  Fahr.),  for 
twenty  minutes  at  a  time,  four  times  a  day,  should  drink  as  much 
[water]  as  possible ;  and  Debove  says :  "  II  ne  suffit  pas  de  le 
laisser  boire,  il  faut  le  /aire  boire"  adding:  "Perhaps,  indeed,  if 
cold  water  baths  have  any  beneficial  effect,  they  owe  it  simply  to 
the  diuresis  which  they  induce." 

Josias. is  rapturous  in  his  praise  of  cool  baths,  given  at  18°  C. 
(64*4°  F.)  every  three  hours  and  for  15  minutes  at  a  time.  These 
baths  should  be  suspended  only  in  cases  of  intestinal  haemorrhages. 
Menstruation,  affections  of  the  respiratory  organs  (bronchitis, 
pulmonary  congestion,  pneumonia,  emphysema),  or  of  the  renal 
organs  (albuminuria),  offer  no  contra-indication  to  the  employment 
of  baths. 

v'  Thanks  to  cold  baths,"  he  says,  "  a  typhoid  fever  is  no  longer 
'typhoid'  except  in  name;  patients  thus  treated  are  no  longer 
prostrate,  present  no  stupor,  but  remain  lively  and  clear-headed  ; 
their  tongues  are  moist,  their  thirst  is  extreme,  which  permits  of  an 
allowance  of  some  4  to  5  litres  (7  to  9  pints)  of  liquids,  nourishing 
or  otherwise.  Excessive  diarrhoea  and  polyuria  are  observed  ;  this 
diarrhoea,  but  particularly  this  polyuria,  are  such  that  the  patient 
a  La  Pru^'ve  Journaliere  des  Hdpitaux  de  Paris.    1391.     Pages  163,  et  seq. 


ENTERIC    FEVER.  453 

may  be  considered  as  daily  washing  out  his  intestines  and  kidneys. 
But,  in  an  infective  disease  like  typhoid  fever,  such  a  flushing, 
carrying  away  all  the  waste  of  the  organism,  should  not  be  regarded 
save  as  a  positive  advantage." 

An  interesting  discussion  on  the  treatment  of  enteric  fever  took 
place  before  the  Berlin  Medical  Society  in  the  Session  of  1881-85.a 
Senator,  in  opening  the  discussion,  observed  that  at  the  General 
Hospital  at  Hamburg,  between  1874  and  1877,  937  cases  were 
treated  without  cold  baths  and  568  by  means  of  them,  the  mortality 
for  the  two  systems  of  treatment  being  identical,  viz.,  7'2  per  cent. 
In  his  opinion,  as  a  mere  antipyretic,  phenazone  (antipyrin)  and 
such  like  drugs,  act  better  tlian  a  cold  bath,  but  the  latter  is  most 
beneficial  as  a  cutaneous  stimulus. 

Goltdammer,  who  advocated  cold  baths,  stated  that  of  3,600 
cases  treated  at  the  Bethaneum  the  mortality  was  12'8  per  cent., 
but  that  if  the  cases  which  were  admitted  later  than  the  second 
week  (of  which  the  mortality  was  36  per  cent,  and  which,  there- 
fore, had  no  baths  during  the  most  important  period)  were  excluded, 
the  mortality  fell  to  9  per  cent.  The  mortality  of  cases  over  forty 
years  of  age  was  41  per  cent. 

During  the  years  1849-64  the  typhoid  mortality  in  the  Second 
Army  Corps  at  Stettin  was  25*9  per  cent. ;  after  the  introduction  in 
1865  of  cold  bathing  it  fell  to  8  per  cent.  The  mortality  among 
the  cases  in  the  Prussian  Army  is  10  per  cent.,  in  the  Austrian 
26-8,  in  the  Italian  28*36,  and  in  the  French  36-5  per  cent. 
The  expectant  method,  Goltdammer  considered,  gave  very  bad 
results. 

Sajous,b  who  may  be  regarded  as  a  recognised  exponent  of 
American  medical  opinion,  writing  in  1891,  says  that  "the  Brand 
treatment  seems  at  last  to  be  winning  its  long-deferred  recognition 
as  the  method  par  excellence  of  managing  enteric  fever."'  He  quotes 
the  favourable  opinion  of  the  method  expressed  by  Dr.  F.  E.  Hare, 
Resident  Medical  Officer  in  the  Brisbane  Hospital,  Australia,  in  two 

a  Verliandlungen  der  Berliner  mediciniscken  Geselhchaft,  1884-85,  and  London 
Medical  Record,  December  15,  1886,  page  557. 

b  Annual  of  the  Universal  Medical  Sciences.     1891.     Vol.  I.     H.-54. 


454  ENTERIC    FEVER. 

communications  on  the  subject.  Tn  the  latter  of  these,*  Dr.  Hare 
compares  the  mortality  in  1,828  cases  during  the  period  of  expec- 
tant treatment  (271  deaths,  or  14*8  per  cent.)  with  that  in  171 
cases  during  a  period  of  incomplete  bath-treatment  (21  deaths,  or 
12-3  per  cent.)  and  in  797  cases  during  the  period  of  strict  bath 
treatment  (56  deaths,  or  7'0  per  cent.).  In  the  last  group,  15  of 
the  fatal  cases  should  be  deducted.  Excluding  these,  782  cases 
gave  a  death-rate  of  5 -2  per  cent. 

In  The  Lancet  for  1890  (Vol.  I.,  page  690)  Dr.  James  Barr, 
Physician  to  the  Northern  Hospital,  Liverpool,  speaks  highly  of 
prolonged  immersion  in  what  he  calls  the  "tank  bath."  He  illus- 
trates his  communication  with  notes  of  a  series  of  cases — nine  in 
number — in  which  he  employed  this  method.  In  addition  to  these, 
three  other  cases  were  treated  by  him  in  the  same  way.  All  the 
twelve  patients  recovered.  They  were  immersed  for  periods  vary- 
ing from  six  to  thirty-one  days. 

The  "tank"  used  at  the  Northern  Hospital,  Liverpool,  consists 
of  a  well-made  wooden  box  6ft.  long,  2ft.  10  inches  wide,  and  12 
inches  deep.  It  is  lined  with  lead,  which  is  painted  white,  and 
coated  with  a  thick  layer  of  shellac  varnish.  The  shellac  makes 
the  tank,  on  other  occasions,  a  convenient  medium  for  administering 
electric  baths.  Each  tank  is  provided  with  a  large  discharge  pipe, 
which  in  the  case  of  these  tanks  communicates  with  a  soil-pipe, 
Which  leads  down  to  the  sewer :  the  tank,  containing  70  gallons  of 
water,  can  thus  be  emptied  in  three  minutes.  To  the  tanks  hot 
and  cold  water  are  plentifully  supplied.  Each  tank  is  provided 
with  a  sheet  of  bed-ticking,  which  would  almost  allow  the  patient 
to  be  submerged,  but  at  the  head  there  is  a  strip,  about  a  foot  wide, 
which  does  not  sink  so  deeply,  and  on  which  rests  an  air-pillow  so 
as  to  keep  the  head  above  water. 

The  patient  is  wrapped  up  in  a  blanket  and  completely  immersed, 
except  the  head.  The  tank  is  covered  with  a  half  lid,  which  pre- 
vents the  weight  of  the  bed-clothing  resting  on  the  patient,  a  water- 
proof sheet,  and  bed-clothing  to  keep  in  the  heat  of  the  water.  A 
thermometer  is  kept  constantly  in  the  tank.  As  long  as  the 
B  Australasian  Medical  Gazette.     July,  1889.     Sydney. 


KNTEUiC    FEVER.  433 

patient's  temperature  is  over  100°,  the  temperature  of  the  tank  need 
not  rise  above  90°  to  93°  ;  but  as  the  body  temperature  approaches 
the  normal,  so  also  should  the  tank  temperature.  Dr.  Barr  did  not 
find  it  necessary  to  lower  the  temperature  of  the  water  below  90° 
or  to  raise  it  above  98°.  By  regulating  the  heat  of  the  water  in 
the  tank,  there  is  no  fear  of  any  collapse,  as  the  temperature  of  the 
body  cannot  fall  below  that  of  the  surrounding  medium. 

Anxious  that  the  patients  while  immersed  should  be  as  little 
disturbed  as  possible,  Dr.  Barr  enjoined  them  to  pass  their  urine 
and  faeces  into  the  tank.  But  he  himself  admits  that  there  are 
grave  objections  to  this,  and  that  so  far  he  has  been  unable  to  devise 
satisfactory  means  of  rendering  the  water  in  the  tank  aseptic. 
Hence  he  thinks  it  will  probably  be  best  in  most  cases  to  raise  the 
patient  above  the  water  while  the  bowels  are  being  moved. 

The  patients  subjected  to  the  immersion  treatment  were  kept 
chiefly  on  a  milk  diet,  but  Dr.  Barr  found  that  in  the  tank  they 
digested  boiled  bread  and  milk  very  well,  notwithstanding  the 
opinion  of  Dr.  Lauder  Brunton  that  farinaceous  food  in  enteric 
fever  on  several  occasions  seemed  to  him  "  to  afford  a  more  favour- 
able nutrient  medium  to  the  bacilli."  None  of  the  patients  had 
any  alcohol  during  their  residence  in  hospital.  Also,  they  had 
very  little  physic.  When  there  is  constipation  calomel  in  small 
doses  appears  to  Dr.  Barr  to  be  perhaps  the  best  purgative.  Naph- 
thaline, as  recommended  by  Rosenbach,  was  prescribed  to  procure 
intestinal  antisepsis,  chiefly  on  account  of  its  very  slight  solubility. 

The  effects  of  the  immersion  treatment  were  briefly  the  follow- 
ing:— 

1.  Temperature. — Dr.  Barr  considers  that  the  tank  effects  a  true 
antipyretic  action,  where  the  thermogenesis  is  diminished,  the 
thermolysis  regulated,  and  the  thermotaxic  mechanism  is  improved. 

2.  Circulatory  System. — There  is  a  marked  improvement  in  the 
vaso-motor  tone :  the  blood-vessels  become  smaller  and  firmer ;  the 
pulse  slower,  fuller,  and  of  improved  tension  ;  the  heart  maintains 
its  vigour.  There  was  no  intestinal  haemorrhage  in  any  of  the 
cases,  and  Dr.  Barr  is  inclined  to  think  that  the  tank  lessens  the 

iability  to  this  complication,  because,  without  doubt,  the  improved 


456  ENTERIC    FEVER. 

vaso-motor  tone  extends  to  the  abdominal  vessels,  as  shown  by  the 
lessened  diarrhoea,  the  diminution  in  the  distension  of  the  abdomen, 
and  the  rise  in  the  arterial  tension. 

3.  Respiratory  System. — The  rate  of  breathing  lessens  in 
frequency,  the  bronchitis  and  congestion  of  the  lungs  improve  and 
soon  disappear. 

4.  Digestive  System. — The  improvement  in  the  digestive  tract 
is,  perhaps,  more  marked  than  anywhere  else.  The  tongue 
becomes  moist  and  clean,  the  salivary  secretion  increases,  the 
appetite  and  digestion  improve,  and  the  diarrhoea  not  only  lessens, 
but  the  character  of  the  motions  changes  for  the  better. 

5.  Nervous  System. — The  delirium  disappears,  and  the  general 
well-being  of  the  patient  greatly  improves. 

6.  Skin — The  horny  layers  of  the  palms  of  the  hands  and  soles 
of  the  feet  get  quite  macerated ;  but  on  the  skin  of  the  body 
generally  there  is  very  little  effect,  with  the  exception  of  a  slight 
roughness  and  elevation  of  the  papillae. 

7.  The  Tissues  in  general.— There  is  marked  diminution  in 
dehydration  of  the  tissues,  which  takes  place  in  all  febrile  condi- 
tions. This  is  very  apparent  in  the  case  of  the  tongue,  which 
maintains  its  proper  size  and  keeps  moist. 

While  he  advocates  the  treatment  of  enteric  fever  by  baths,  Dr. 
Cayley  impartially  discusses  three  chief  objections  which  have  been 
advanced  to  the  adoption  of  this  method  of  treatment.  These 
are : — 

First — It  is  dangerous  to  the  patient,  from  its  being  likely  to 
cause  collapse,  intestinal  haemorrhage,  congestion,  and  inflamma- 
tion of  the  lungs. 

Secondly — The  great  mechanical  difficulty  in  carrying  it  out. 

Thirdly — The  discomfort  and  pain  it  causes  the  patients,  and 
their  consequent  repugnance  to  submit  to  it. 

Dr.  Cayley  shows  very  clearly  that  the  first  of  these  objections 
has  no  foundation  in  fact.  In  2,068  cases  reported  by  Dr. 
Goltdammer,  there  was  only  one  instance  of  fatal  collapse.  This 
accident  can  occur  only  when  the  treatment  has  been  deferred  until 
the  later  or  adynamic  stages  of  the  fever,  and.  may  be  obviated  by 


ENTERIC    FEVER.  457 

raising  the  temperature  of  the  water  in  the  bath.  Dr.  Barr  also 
pointed  this  out.  The  frequency  of  intestinal  haemorrhage,  again, 
is  not  increased  by  the  bath,  rather  the  reverse.  At  the  same 
time,  Cayley  admits  that,  should  haemorrhage  or  peritonitis  occur, 
the  bathing  must  be  at  once  intermitted,  as  perfect  quiet  is  requi- 
site. 

With  regard  to  lung  complications,  Dr.  Cayley  thinks  it  cannot 
be  doubted  but  that,  when  the  bathing  treatment  is  begun  early 
enough,  it  has  a  marked  effect  in  preventing  them. 

The  mechanical  difficulties  are.  no  doubt,  hard  to  get  over  in 
private  practice ;  but  they  are  not  insuperable,  and  in  every  pro- 
perly equipped  General  or  Private  Hospital  suitable  apparatus  for 
the  purpose  should  be  available.  Dr.  Cayley,  in  his  edition  of 
Murchison's  "Treatise  on  the  Continued  Fevers,"  describes  such 
an  apparatus,  constructed  by  Mr.  Hawksley,  the  surgical  instru- 
ment maker,  of  Oxford-street,  London,  and  planned  by  Mr.  E.  A. 
Fardon,  at  the  time  Resident  Medical  Officer  of  the  Middlesex 
Hospital. 

It  consists  of  two  uprights,  which  move  on  wheels,  and  a  cross- 
bar. A  kind  of  hammock  made  of  strips  of  webbing  is  placed 
under  the  patient,  and  then  attached  by  a  suspender  to  the  cross- 
bar. By  means  of  pulleys  and  an  endless  chain  the  hammock  is 
lifted  from  the  bed,  then  slid  along  the  bar  till  it  is  over  the  bath, 
and  let  down  into  it  and  drawn  up  again  in  the  same  manner.  Not 
only  does  this  entirely  relieve  the  nurses  of  any  strain,  but  it  is 
both  safer  and  more  comfortable  for  the  patient.  It  takes,  how- 
ever, longer  to  bathe  a  patient  in  this  way  than  by  simply  lifting 
him  into  the  bath. 

In  reference  to  the  possible  repugnance  of  the  patient  to  the  bath, 
Cayley  observes  that  with  judicious  management  he  has  met  with 
very  little  difficulty  from  this  cause.  In  a  large  number  of  cases 
the  relief  given  to  the  febrile  oppression  is  so  great  that  the  bath  is 
grateful ;  in  other  cases,  though  disagreeable,  the  patients  are  quite 
willing  to  submit  in  view  of  the  after-relief.  In  all  cases  the 
temperature  and  duration  of  the  bath  must  be  adapted  to  the  con- 
dition and  feelings  of  the  patient  and  the  effect  it  produces.     Other 


458  EXTERTC    FEVER. 

means  of  reducing  temperature  must  be  employed  where  the  bath 
is  objected  to  or  produces  unfavourable  symptoms. 

(B.)  Dr.  A.  de  Souza  a  recommends  lowering  of  the  temperature 
in  fever  by  means  of  the  ambient  air.  This  method  of  reducing 
bodily  temperature  is  especially  applicable,  according  to  him,  in 
enteric,  hectic,  and  tubercular  fevers.  In  winter  he  keeps  the  room 
in  which  the  patients  are  from  8°  to  10°  C.  (46-4°  to  50°  Fahr .), 
the  only  bed-covering  being  a  sheet  and  one  blanket ;  if  towards 
the  end  of  the  night  the  temperature  of  the  room  or  of  the  patients 
falls  considerably,  something  extra  is  thrown  over  the  feet.  The 
higher  the  fever,  the  lower  is  the  temperature  of  the  room  to  be 
kept.  If  the  air  of  the  room  be  gradually  cooled,  the  patients  do 
not  notice  or  soon  become  accustomed  to  the  fresher  atmosphere. 
In  summer  even,  much  may  be  done  by  proper  ventilation  and  by 
diminishing  the  bed-clothes.  Cold  lotions  and  baths  may  also 
assist. 

(C.)  A  third  way  of  reducing  temperature  is  by  the  action  of 
drugs,  called  in  consequence  "  antipyretics."  Never  very  partial 
to  this  method,  I  confess  that  since  I  read  Cantani's  Address  on 
"  Antipyresis,"  already  quoted  on  more  than  one  occasion  in  this 
book,  I  have  become  more  chary  than  ever  in  the  use  of  anti- 
pyretics in  fever.  The  views  of  this  enlightened  physician  have 
been  stated  at  pages  7  and  53,  and  need  not  be  recapitulated  here. 

At  the  same  time,  it  is  necessary  to  allude  to  some  of  the 
remedies  included  under  the  heading  "  Antipyretics." 

1.  Quinine  deservedly  occupies  the  first  place  in  the  list.  It  may 
be  given  in  suspension  in  water,  or  in  milk  with  3  to  5  grains  of 
camphor,  in  5 -grain  doses  every  third  hour,  or  in  still  larger  doses 
(10  grains)  every  ten  minutes  until  the  desired  quantity — 20  to  40 
grains — has  been  taken.  This  remedy  is  particularly  useful  in  the 
later  stages  of  the  disease,  when  the  fever  has  a  remittent  type. 
Children  bear  quinine  well  (Barthez  and  Rilliet,  1853). 

2.  Salicin,  salicylic  acid,  the  salicylates,  and  salol  are  not 
trustworthy  antipyretics  in  enteric  fever.  Salicylate  of  sodium  in 
repeated  doses  of  10  to  20  grains  has,  at  the  Meath  Hospital,  pro- 

*  El  Monitor  Medico.     September,  1886. 


ENTERIC    FEVER.  4")'.) 

duced  toxic  symptoms,  with  temporary  depression  of  the  heart's 
action  and  delirium.  Albuminuria  has  also  been  observed  else- 
where after  its  free  administration. 

3.  The  great  group  of  coal-tar  derivatives  may  next  be  con- 
sidered. Of  these,  the  best  known  is  phenazone  (antipyrin),  now 
official,  but  objectionable  as  an  antipyretic  in  fever  because  of  its 
depressant  action.  To  children  it  should  be  given  with  the  greatest 
caution.  Acetanilide  (antifebrin),  also  official,  is  an  excellent 
febrifuge,  particularly  when  prescribed  with  quinine — 3  grains  of 
antifebrin  and  2  grains  of  quinine,  repeated  every  third  or  fourth 
hour,  while  necessary.  Kairin  (C10Hl3NO)  was  introduced  into 
practice  as  an  antipyretic  by  Dr.  Wilhelm  Filehne,a  in  1883.  He 
recommended  doses  of  from  7  to  15  grains,  repeated  hourly  until 
temperature  falls.  Its  taste  is  horrible — saline,  bitter,  and  per- 
sistently nauseous — so  it  should  be  prescribed  either  in  pills,  with 
glycerine  of  tragacanth,  or  in  cachets  (Martindale).  It  is  efficient, 
but  its  effects  are  evanescent,  and  it  is  apt  to  depress  the  heart  and 
cause  collapse  with  cyanosis.  Thallin  (the  sulphate  of  tetrahydro- 
paramethyloxychinolin !)  in  3  or  4  grain  doses,  reduces  temperature 
readily;  but  this  remedy,  also,  is  not  free  from  danger,  and  is 
contraindicated  in  cardiac  weakness  or  kidney  disease. 

4.  Digitalis  in  large  doses  has  a  powerful  action  in  reducing 
temperature,  and  is  highly  recommended  by  Liebermeister, b  Wun- 
derlich,0  Thomas,  and  other  German  physicians.  Liebermeister 
prescribes  it  in  powder  or  in  pills,  giving  from  1 1  to  22  grains  in 
36  hours,  and  following  it  up  by  a  k'full  dose"  (30  to  45  grains)  of 
quinine.  "  Its  use  in  these  large  doses,"  says  Cayley,  "  can  hardly 
be  regarded  as  quite  free  from  danger."  Even  Liebermeister  states 
that  it  is  to  be  used  only  where  there  is  no  considerable  degree  of 
cardiac  weakness,  and  where  the  pulse  is  not  yet  extremely  frequent. 
He  adds — hardly  for  our  encouragement — "  The  impending  para- 
lysis of  the  heart  is  not  prevented  by  the  use  of  this  drug,  but 
seems  rather  to  be  favoured  thereby. 

•  Berlin  klin.  Wochensch.     1883.     Nos.  6,  16. 

b  Von  Ziemssen's  Cyclopcedia  of  Pract.  Med.     1875.     Vol.  I.,  page  217. 
c  Ueber  den  Nutzen  der  Diyitalisanwendung  beim  enterischen  Typhus.    Aruhiv. 
der  Heilkunde.     1862.     Page  97. 


4(50  ENTERIC    FEVER. 

5.  Veratria,  in  comparatively  large  doses  (j^th  of  a  grain  in 
pill  every  second  hour  until  decided  nausea  or  vomiting  ensues), 
was  recommended  by  W.  Vogt,  and  employed  by  Liebermeister. 
It  is  a  remedy  which  will  not  commend  itself  to  British  physicians 
in  the  treatment  of  enteric  fever. 

6.  The  antiseptic  and  antipyretic  methods  of  treatment  have 
recently  been  combined  by  Dr.  E.  Tordeus,  of  Brussels,*  who  gives 
resorcin  or  thymic  acid  as  an  antiseptic  together  with  acetanilide 
as  an  antipyretic.  The  dose  usually  employed  by  Dr.  Tordeus  was 
three-quarters  of  a  grain  of  thymic  acid  and  from  one  and  a  half 
to  two  grains  of  acetanilide,  repeated  not  too  frequently,  say  every 
two  hours.  Resorcin  is  best  administered,  according  to  Martindale, 
well  diluted  with  water  and  flavoured  with  syrup  of  orange  or 
glycerine.  By  the  doses  mentioned,  the  temperature  was  reduced 
in  enteric  fever  from  104°  to  nearly  normal,  without  any  unfavour- 
able symptoms  accruing. 

This  long  list  of  antipyretics  may  appropriately  be  closed  with  a 
quotation  from  Dr.  Hilton  Fagge.  "  It  seems  to  be  grateful  to 
most  patients,"  he  observes,  "  to  take  what  is  called  '  a  simple 
febrifuge,'  such  as  ten  drops  of  dilute  hydrochloric  acid  in  infusion 
of  orange,  of  calumba,  or  of  serpentary.  It  is  probably  a  mere 
placebo,  but  there  is  every  reason  to  please  as  well  as  to  cure  our 
patients." 

a  Nouveau  Traitement  de  la  Fi&vre  Typhoide.  Journal  de  med.,  chir.,  tt pharma- 
cologic.    Bruxelles.     1891.     Vol.  XC1L,  pages  325-332. 


4(51 


CHAPTER  XLVII. 

Curative   Treatment  of   Enteric   Fever  (Continued). 

Treatment  of  certain  Complications  and  Sequelae. 

Strong  Decoction  of  Coffee  and  Caffein  in  Ataxia  and  Adynamia. — 
Inhalation  of  Oxygen  in  Broncho-pneumonia. — Prevention  of  Bedsores. — 
Treatment  of  Epistaxis.— Treatment  of  Intestinal  Symptoms,  Complica- 
tions, and  Sequels :  Constipation,  diarrhoea,  tympanites  or  meteorism, 
vomiting,  abdominal  pain,  haemorrhage  from  tbe  bowels,  peritonitis,  perforation, 
medical  and  surgical  measures. 

VI.  Little  need  be  said  in  this  Chapter  about  the  treatment  of 
the  complications  and  sequelae  of  enteric  fever  which  engage  the 
systems  of  the  body  other  than  the  digestive  tract.  For  the  rules 
already  laid  down  for  the  management  of  the  cerebral  and  cardiac 
affections  of  typhus,  the  pulmonary  affections  of  measles,  and  the 
anginal  and  renal  affections  of  scarlatina,  apply  equally  to  those 
cases  of  enteric  fever  in  which  similar  complications  may  happen 
to  arise. 

The  great  subject  of  the  treatment  of  the  intestinal  complications 
which  are  almost  peculiar  to  enteric  fever,  however,  remains  to  be 
discussed. 

Before  I  take  up  this  topic,  I  would  like  to  allude  to  a  few 
troublesome  complications  and  to  certain  remedies  which  have  not 
hitherto  been  mentioned  in  connection  with  the  special  lesions  to 
combat  which  their  employment  is  indicated. 

In  well-marked  ataxia  and  adynamia  of  fever,  the  administration 
of  a  strong  decoction  of  coffee  (cafe  'not?')  is  often  followed  by  highly 
beneficial  results.  And,  in  accordance  with  its  physiological  action, 
the  active  principle  of  coffee  called  caffein  is  employed  as  a  cerebral 
and  cardiac  stimulant,  particularly  in  bad  fevers.  According  to 
Huchard,  of  Paris,  caffein,  exhibited  endermically,  gives  excellent 
results  in  ataxo-adynamie  enteric  fever.     It  is  a  general  tonic  in 


462  ENTERIC    FEVER. 

adynamic  states.  Caffe'in  is  very  soluble  in  aqueous  solutions  of 
benzoate,  cinnamate,  and  salicylate  of  sodium.  These  dissolve  it  in 
chemically  equivalent  quantities.  Martindale  says  that  the  follow- 
ing salicylate  of  sodium  solution  of  it  forms  an  unirritating 
hypodermic  injection  : — 

R    Caffeinae,  gr.  20  ; 

Sodii  Salicylatis,  gr.  1 1\  ; 
Aquae  destillatae,  ad  3i- 
Dose :   1  to  6  minims.     This  solution  contains  one  grain  in  three 
minims. 

Huchard  employs  two  solutions — a  weak  and  a  strong.     The 
formula?  for  these  are  as  follows  : — 
No.   1.    Weak  — 

R    Sodii  Benzoatis,  gr.  45  ; 
Caffeinae,  gr.  30 ; 
Aquae  destillatae,  3>ss» 
Make  a  solution  by  warming. 
No.  2.  Strong — 

R     Sodii  salicylatis,  gr.  47 ; 
Caffeinae,  gr.  60  ; 
Aquae  destillatae,  3'ss. 
Make  a  solution  by  warming. 
Another  remedy  worth  noting  is  inhalation  of  oxygen.     In  the 
'•Medical  and  Surgical  Reports  of  Cook  County  Hospital,  1890,"  a 
will  be  found  an   account  of  inhalation   of   oxygen   in  a  case  of 
typhoid  fever  complicated  by  broncho-pneumonia. 

Bedsores  may  be  prevented  by  scrupulous  cleanliness  and  the 
use  of  the  water-bed.  The  parts  should  be  kept  dry  and  freely 
dusted  with  some  emollient  powder.  Daily  friction  with  spirit  of 
camphor,  eau  de  Cologne,  whisky,  or  brandy,  is  a  good  preventive. 

Epistaxis,  or  nose-bleeding,  is  sometimes  so  profuse  and  so 
obstinate  as  to  call  for  special  treatment.  The  drugs  afterwards 
recommended  in  intestinal  haemorrhage  may  be  prescribed.  A 
bladder  of  ice  should  be  applied  over  the  forehead  and  nose  ;  while 
"  hazeline  "  (an  aqueous  solution  of  hamamelis),  infusion  of  matico 
'Chicago.     1891.     Pages  125-127. 


ENTERIC    FEVER.  463 

or  of  rhatany,  or  a  solution  of  alum  or  of  tannin  should  be  injected 
into  the  nostrils.  Hot  water  injections  may  also  be  tried,  and  these 
measures  failing,  the  posterior  nares  should  be  plugged. 

The  symptoms  and  complications  connected  with  the  digestive 
system  in  enteric  fever  which  call  for  special  treatment  are  tlie 
following: — (1).  Constipation;  (2).  Diarrhoea;  (3).  Tympanites, 
or  Meteorism ;  (4).  Vomiting ;  (5).  Abdominal  Pain ;  (6). 
Haemorrhage  from  the  Bowels ;    (7).  Peritonitis  ;    (8).  Perforation. 

1.  In  treating  constipation,  we  should  never  forget  the  advice 
tendered  by  Baglivi,a  two  centuries  ago,  that  in  the  treatment  of 
"  Febris  mesenterica  maligna,"  all  drastic  purgatives  are  "  to  be 
shunned  like  the  plague."  In  the  early  stage  of  enteric  fever,  an 
experience  of  many  years  has  satisfied  me  that  a  moderate  dose  of 
calomel  (from  3  to  5  grains)  is  often  beneficial,  and  effectually 
overcomes  constipation.  After  the  first  week  or  ten  days,  calomel 
should  be  given  with  caution.  Three  other  plans  may  then  be 
tried  either  in  rotation  or  alternately.  First,  diet  may  be  so 
arranged  as  to  act  as  a  laxative — beef-tea,  or  strained  mutton 
broth  may  be  allowed  ;  or  ripe  orange  juice,  or  a  few  grapes  care- 
fully deprived  of  their  skin  and  seeds.  Secondly,  a  simple  enema 
may  be  administered  every  thirty-six  or  forty-eight  hours,  according 
to  circumstances.  Trousseau  used  an  enema  of  chamomile  infu- 
sion. On  no  account,  however,  should  a  glycerine  enema  be 
ordered  after  the  first  few  days  of  enteric  fever — the  increased 
peristalsis  on  which  its  efficacy  depends  might  lead  to  dangerous 
consequences — inflammation,  or  perforation.  Thirdly,  an  excellent 
remedy  for  constipation  is  castor  oil  in  small  doses,  as  both 
Trousseau  and  Murchison  recommend.  My  favourite  prescription 
is  to  mix  a  teaspoonful  of  glycerine  with  a  wineglassful  of  warm 
milk,  and  then  to  add  a  teaspoonful  of  castor  oil.  This  dose,  or 
draught,  may  be  repeated  in  six  or  eight  hours,  until  the  bowels 
are  freed.  It  is  a  specially  useful  remedy  in  the  constipation  of 
convalescence. 

Hilton  Fagge  discountenances  any  interference  with  constipa- 
tion in  enteric  fever.     He  thinks  it  better  to  err  on  the  side  of 

a  Baglivi.     Opera  omnia.     Romse.     1696.     Editio  sexta.     Lugdimi.     1704. 


464  ENTERIC    FEVER. 

caution,  and  to  abstain  from  meddling  with  the  bowels  until  con- 
valescence is  established. 

2.  Diarrhoea. — This  is  not  only  a  common  symptom,  but  some- 
times a  serious  complication  of  enteric  fever,  and  if  unchecked  may 
run  down  the  patient's  strength,  and  so  endanger  his  life.  Our 
object  should  be — not,  as  recommended  by  the  late  Dr.  Todd,  in 
1860,  to  lock  up  the  bowels,  and  keep  them  so;  but  to  check 
diarrhoea,  limiting  the  motions  to  two  in  the  twenty-four  hours,  if 
possible. 

An  excellent  remedy  is  a  small  starch  enema,  containing  ten  to 
twenty  drops  of  laudanum.  This  stays  peristaltic  action  and  gene- 
rally controls  the  milder  forms  of  diarrhoea. 

Much,  too,  may  be  effected  by  a  change  of  diet.  The  milk  should 
be  boiled  and  mixed  with  lime-water  in  the  proportion  of  3,  or  only 
2,  parts  of  milk  to  1  of  lime-water.  Dr.  T.  W.  Grimshawa  used 
to  employ  the  saccharated  solution  of  lime  in  proportional  doses — 
this  preparation  being  about  14  times  stronger  than  plain  lime- 
water.  Beef-tea  should  be  withheld,  and  to  each  teacupful  of 
chicken  broth  a  teaspoonful  of  stiff  isinglass  jelly  (gelatine)  should 
be  added.  Thin  arrowroot  may  also  be  allowed,  or  rice-milk. 
Above  all,  the  quantity  as  well  as  the  quality  of  the  food  should  be 
controlled. 

Local  applications  to  the  abdomen  often  do  good.  For  example  : 
light  linseed  meal  poultices,  turpentine  epithems,  mustard  fomen- 
tations, and  wet-compresses,  may  be  tried  in  turn  or  singly.  As 
regards  poulticing  in  this  fever,  I  long  since  gave  up  the  applica- 
tion to  the  abdomen  of  bulky  linseed  meal  poultices  (which  are 
positively  dangerous  from  a  mechanical  point  of  view)  in  favour  of 
the  following:  .A  piece  of  lint  of  suitable  size  is  moistened  with  a 
warmed  mixture  of  laudanum  (one  fluid  drachm),  glycerine  (seven 
fluid  drachms),  and  water  (seven  fluid  ounces),  and  laid  over  the 
abdomen.  Oiled  silk  or  gutta-percha  tissue  is  then  applied,  over 
which  is  placed  a  sheet  of  French  wadding,  or  medicated  cotton- 
wool— the  whole  being  kept  in  position  by  a  soft  flannel  roller  or 

a  "  On  the  Management  of  the  Bowels  in  Enteric  Fever."  Dubl.  Journ.  of 
Med.  Science.     Vol-  LXIIL,  page  132.     1877. 


ENTERIC   FEVER.  465 

bondage,     This  ""glycerine  poultice,"  or  "  glycerine  compress,"  as 
it  may  be  called,  is  at  once  comfortable  and  efficient. 

Trousseau*  used  to  treat  diarrhoea  in  dothie'nenterie  by  ordering 
in  the  first  instance  a  saline  purge,  a  neutral  salt,  25  to  30  grammes 
of  sulphate  of  sodium  or  a  seidlitz  powder,  as  an  alterative  or  modi- 
fier of  the  intestinal  secretions.     Tliis  treatment  he  considered  to  be 
especially  applicable  when  the   diarrhoea  was  accompanied  by  a 
certain  degree  of  meteorism.     If  the  desired  result  was  not  obtained, 
he  used  to  prescribe  so-called  "absorbent  powders,"  a  mixture  of 
7i  grains  of  subnitrate  of  bismuth  with  an  equal  quantity  of  pre- 
pared chalk — this  dose  being  repeated  three,  four,  six,  eight  times 
in  the  twenty-four  hours,  or   even  oftener  according  to  circum- 
stances.    He  also  frequently  gave  "la  mixture  anglaise,"  namely, 
R.  Creta3  Prseparatffi,  5J ;     • 
Syrupi  Aurantii  Corticis,  §j ; 
™  Aqua?,  §iij. 

Powdered  calumba  root  in  doses  of  from  7^  to  15  grains  was 
another  favourite  remedy  with  him.  If  these  means  failed,  he  had 
recourse  to  pills  containing  about  one-tenth  of  a  grain  of  nitrate  of 
silver  irt  washed  bread-crumb  {mie  d&pain).  Of  these  one  was  to 
be  taken  every  hour  in  the  course  of  the  day. 

If  the  "  Mistura  Cretae"  of  the  British  Pharmacopoeia  is  pre- 
scribed, it  should  be  ordered  to  be  prepared  afresh,  as  in  my 
experience  it  is  a  mixture  which  does  not  keep  well.  Instead  of 
ordering  it  I  much  prefer  to  prescribe  a  mixture  containing  aromatic 
chalk  powder,  with  or  without  opium,  compound  tincture  of  chloro- 
form,'powdered  gum  acacia,  and  cinnamon  water.  "  Chlorodyne," 
or  its  pharmacopoeia!  equivalent — the  tincture  of  chloroform  and 
morphin — may  be  substituted  in  this  mixture  for  the  compound 
tincture  of  chloroform.    '      ;      :-     -  ' 

Murchison  gives  the  following  favourite  prescription  :— • 
R.  Acid.  Sulphurici  Aromat.,  min.  xx; 

Liquor.  Opii  Sedativi  (Battley)  min.  iij ;-  " 
Tincturae  Catechu,  3  -*s  ; 
Aquas  Menthas  Piperita?, -gj. 
a  Clinique  Medicate  de  VHdtel  Dieu  de  Paris.  •  1865.    Tome  I.$  pages  258,  259. 

2    H 


466  ENTERIC   FEVER. 

M.  ft.  haustus.  Signa:  "The  draught  to  be  taken  every  third 
or  sixth  hour." 

Other  remedies  employed  by  Murchison  were — Vegetable  charcoal 
in  teaspoonful  doses  every  fourth  hour  (especially  useful  in  diarrhoea 
accompanied  by  tympanites) ;  powders  of  equal  parts  of  Dover's 
powder  and  gray  powder ;  or  acetate  of  lead  in  solution  in  doses  of 
2  or  3  grains  every  four  or  six  hours,  with  or  without  one-twelfth 
of  a  grain  of  acetate  of  morphin. 

Dr.  Grimshaw  gave  dilute  sulphuric  acid  in  the  proportion  of  3 
drachms  in  an  eight-ounce  mixture,  of  which  an  ounce  was  to  be 
taken  every  three  hours.  Sometimes  he  added  to  the  mixture 
small  quantities  of  solution  of  morphin,  or  of  tincture  of  opium.  In 
more  urgent  cases  he  employed  the  lead  and  opium  pills  of  the 
Pharmacopoeia,  in  four-grain  doses  every  fourth  hour,  with  great 
benefit. 

Dr.  Samuel  Fenwick8  speaks  highly  of  sulphate  of  copper — one 
quarter  of  a  grain  with  one  quarter  of  a  grain  of  opium  every  three 
hours.  Murchison  has  an  alternative  prescription,  according  to 
which  a  quarter  of  a  grain  of  sulphate  of  copper  may  be  given  in 
solution  with  sulphuric  acid,  quinine,  and  a  few  drops  of  laudanum 
every  four  or  six  hours. 

Liebermeister  lets  moderate  diarrhoea  alone  ;  but  in  severe  cases  he 
administers  opium  in  small  and  repeated  doses,  sometimes  in  com- 
bination with  ipecacuanha  or  nux  vomica,  and  sometimes  with 
tannin,  alum,  or  other  astringents. 

Twenty  years  ago,  Dr.  James  Little  asked  Dr.  Alfred  Hudson  to 
see  a  lady  suffering  from  enteric  fever  in  whom  looseness  of  the 
bowels  was  the  chief  trouble,  and  he  suggested  a  pill  consisting  of 
one-sixth  of  a  grain  of  carbolic  acid,  one-sixth  of  a  grain  of  extract 
of  opium,  and  three  grains  of  trisnitrate  of  bismuth,  to  be  taken 
after  each  loose  stool.  Dr.  Little  informs  me  that  he  found  this 
pill  so  useful  that  he  has  commonly  used  it  since,  employing  during 
the  past  two  years  the  salicylate  of  bismuth  instead  of  the  tris- 
nitrate. As,  however,  it  often  happens  that  patients  in  enteric 
fever  are  too  ill  to  swallow  a  pill,  Dr.  Little  has,  when  this  was  the 

*  Outlines  of  Medical  Treatment.    Third  Edition.    London.    1891.  Page  454. 


ENTERIC    FEVER.  467 

case,  given  the  same  ingredients  in  a  mixture  of  which  the  formula 
approximately  is — 

fy.  Bismuth!  Salieylatis,  gr.  30  ; 
Pulv.  Acacioe,  3i'  ; 
Tinct.  Opii,  min.  xvii! ; 
Glycerini  Carbolici,  min.  xxx; 
Tinct.  Lavand.  Co.,  5i'i  i 
Aquae,  ad  §vi. 

Signa :  A  sixth  part  two,  three,  or  four  times  in  24  hours,  as 
required. 

I  may  state,  as  a  matter  of  personal  observation,  that  small  doses 
of  turpentine  given  systematically  every  few  hours  from  an  early 
stage  of  the  fever  seem  to  control  the  diarrhoea  in  a  remarkable  and 
satisfactory  manner. 

3,  Tympanites,  or  Meteorism. — In  the  first  place,  I  am  strongly 
of  opinion  that  the  occurrence  of  this  troublesome  and  often  dange- 
rous symptom  may  be  prevented  by  the  turpentine  treatment,  com- 
menced early  and  persevered  in.  No  heroic  doses  are  required,  but 
the  remedy  should  be  given  steadily  through  the  fever.  Dr.  George 
B.  Wood,a  of  America,  long  ago  recommended  turpentine  in  doses 
of  from  5  to  20  minims  every  hour  or  every  second  hour,  in  all 
cases  of  enteric  fever  accompanied  by  tympanites  and  a  dry  tongue. 
In  atonic  ulceration  and  protracted  convalescence,  with  a  dry,  red, 
and  smooth  tongue,  he  regarded  turpentine  almost  in  the  light  of  a 
specific. 

Another  remedy,  which  controls  tympanites,  is  nux  vomica,  or 
its  active  alkaloid,  strychnin.  These  keep  up  intestinal  "tone" 
and  check  undue  distension  of  the  bowel.  Some  years  ago  I  was 
called  to  the  Curragh  in  consultation  to  see  a  young  officer  ill  of 
enteric  fever  with  much  tympanites.  I  advised  3  minim  doses  of 
liquor  strychninae  to  be  exhibited  three  times  a  day,  because  his 
heart  was  weak,  and  with  a  view  of  controlling  tympanites.  A 
few  days  afterwards  intestinal  haemorrhage  occurred,  whereupon 
my   treatment   was,  I  believe,  somewhat  unfavourably  criticised. 

a  Practice  of  Medicine.    Sec md  Edition.     1849.    Vol.  I.,  page  328. 


463  ENTERIC   FEVER. 

But  surely  both  intestinal  haemorrhage  and  perforation  would  be 
more  likely  caused  by  over-distension  of  a  diseased  intestine  than  by 
any  increased  peristalsis  due  to  moderate  doses  of  nux  vomica  or  of. 
strychnin. 

As  the  gas  collects  c  efly  in  the  colon,  Murchison  recommends 
enemata  containing  carbolic  acid  glycerine  (half  a  drachm),  or  six 
minims  of  creasote  with  half  an  ounce  of  glycerine,  or  an  ounce  of 
vegetable  charcoal  with  two  ounces  of  mucilage,  or  two  drachms  of 
spirit  of  turpentine  with  two  ounces  of  olive  oil,  or  two  drachms  of 
asafoetida  with  10  minims  of  oil  of  rue— any  one  of  the  foregoing 
in  a  pint  and  a  half  of  barley  water  (decoctum  hordei).  Of  these 
formulas,  the  only  one  I  object  to  is  that  containing  charcoal,  for 
this  substance  loses  its  absorbent  properties  when  saturated  with  • 
fluid,  and  so  is  practically  inert  and  therefore  useless. 

The  abdomen  should  be  gently  rubbed  in  the  direction  of  the 
colon.  Turpentine  fomentations  may  be  applied  from  time  to  time, 
or  cold  compresses  as  recommended  by  Liebermeister.  Dr.  Peter,'3, 
of  La  Pitie\  Paris,  found  ice  poultices — made  by  scattering  small 
fragments  of  ice  over  a  thick  layer  of  dry  linseed  meal — most  effectual 
for  subduing  the  tympanitic  distension.  As  the  ice  thaws,  a 
poultice  is  formed  which,  in  consequence  of  the  slow  melting  of 
the  ice,  is  kept  at  the  temperature  of  melting  ice.  To  Professor 
Monneret  belongs  the  credit  of  devising  and  introducing  to  the 
profession  this  very  valuable  method  of  treating  tympanites. 
♦  In  Dr.  Cayley's  Opinion,^  the  application  of  ice  to  the  surface  of 
the  abdomen  is  by  far  the  best  way  of  treating  great  distension.: 
It  may  be  conveniently  applied  by  putting  small  pieces  between 
two  folds  of  flannel.  It  is  especially  indicated  in  haemorrhage.  By 
this  means  a  considerable  general  reduction  of  temperature  may  be 
effected.       ' 

Should  tympanites  not  yield  to  the  foregoing  measures,  O'Beirne's 
long  enema  tube  should  be  cautiously  passed  up  the  rectum,  when 
flatus  will  probably  escape  freely  through  it  owing  to  reflex  con- 
fraction  of  the  bowel  and  increased  peristaltic  action.     Puncturing 

a  Brit.  Med  Journal.     Vol.  II.,  page  450.     1869. 
.'--y^  Murchison.     1884.     Third  Edition.     Page  673. 


ENTERIC    FEVER.  4G(.) 

'the  colon  with  a  capillary  trochar  and  cannula  has' been  suggested, 
but  such  a  procedure  is  not  to  be  recommended. 

4.  Vomiting. — The  clinical  significance  of  this  symptom  has 
been  already  discussed  (see  p<ge  376).  In  all  cases  where  vomiting 
occurs,  inquiry  should  be  made  as  to  the  quality  and  quantity  of 
the  food,  and  as  to  the  times  and  frequency  of  feeding. .  Attention 
to  these  details  may  cause  vomiting  to  cease  without  further 
trouble. 

At  the  beginning  of  enteric  fever,  Murchison  states  that  vomiting 
is  often  relieved  by  an  emetic  of  ipecacuanha  (20  grains)  and 
antimony  (one  grain),  or  of  carbonate  of  ammonia  (40  grains).  An 
emetic  should  never  be  administered  after  the  tenth  day  of  enteric- 
fever. 

Other  remedies  are — a  sinapism  or  turpentine  epithem  to  the  pit 
of  the  stomach.  Ice  may  be  sucked — the  patient  being  enjoined  to 
swallow  small  fragments  of  it  .while  still  unmelted.  The  patient 
should  take  milk  and  lime-water  in  equal  parts.  Effervescing 
draughts  or  a  mixture  containing  bismuth  and  dilute  hydrocyanic 
acid  should  be  prescribed.  A  hypodermic  injection  of  3  to  5  minim 
of  liquor  strychnine  is  often  of  use.  So  also  is  "  ingluvin  "  in 
5-grain  doses. 

5.  Abdominal  Pain. — This  troublesome  symptom  is  often  in- 
dependent of  peritonitis.  It  is  best  treated  by  warm  fomentations, 
gentle  massage,  the  application  of  a  light  poultice  or  compress, 
withla  dessertspoonful  of  laudanum  sprinkled  over  it.  Occasionally 
a  single  leech  applied  to  the  right  iliac  region  gives  great  relief. 
Murchison  says  that  from  2  to  6  leeches  may  be  applied  in  this  way 
in  a  young  and  robust  patient,  early  in  the  fever.: 

6.. Hemorrhage  from  the  Bowels.— This  alarming  occurrence, 
if  profuse  in  an  advanced  stage  of  the  disease,  indicates  that  the 
patient  is  in  extreme  danger. 

!  Should  hemorrhage  occur,  the  treatment  by  baths  must  be 
intermitted.  Complete  rest  must  be  insisted  upon,  and  a  hypoder- 
mic injection  of  morphin  should  be  given.  Ice  should  be  sucked, 
and  an  ice-poultice,  or  a  bladder  containing  broken  pieces  of  ice, 
should  be  laid  over  the  right  side  of  the  abdomen  (Murchison). 


470  ENTERIC    FEVER. 

Patients  sometimes  object  to  the  ice-poultice,  and  then  of  course  if. 
must  be  removed. 

As  for  internal  remedies,  those  in  most  request  are — for  acute 
haemophilia,  perchloride  or  pernitrate  of  iron  in  large  doses  ;  for 
local  intestinal  haemorrhage,  gallic  or  tannic  acid,  turpentine, 
rhatany,  hamamelis,  acetate  of  lead,  opium,  and  ergot.  During 
many  years  Murchison  found  the  following  mixture  almost  invariably 
effectual  for  stopping  the  bleeding: — 
I£.  Acidi  Tannici,  gr.   10; 

Tincturae  Opii,  min.  x; 

Spt.  Terebinthinae,  min.  xv ; 

Mucilaginis,  z,\i; 

Tinct.  Chloroformi  Comp.,  min.  xx ; 

Aquae  Menthae  Piperitae,  ad  §i. 
M.  ft.  haustus,  seeunda  quaque  hora  sumendus. 
Dr.  J.  B.  Russell,a  of  Glasgow,  gives  the  tincture  of  ergot  in 
drachm  doses  every  hour,  and  has  never  known  it  fail.  Mnrchisou 
also  speaks  highly  of  ergot,  which  he  considers  to  be  "a  most 
efficacious  styptic,  even  in  the  most  profuse  haemorrhage."  From 
8  to  5  grains  of  "ergotin"  dissolved  in  10  minims  of  distilled 
water,  or  in  equal  parts  of  glycerine  and  rectified  spirit,  may  be 
injected  beneath  the  skin.  The  drug  may  also  be  exhibited  in 
combination  with  turpentine,  in  the  form  prescribed  at  page  124. 

J.  H.  Jenkins,b  in  the  Medical  World,  Philadelphia,  for  September, 
1890,  reports  a  case  of  repeated  profuse  intestinal  haemorrhages 
in  the  fourth  week  of  enteric  fever,  in  which  one  quart  of  blood 
was  transfused  directly  from  the  common  carotid  artery  of  a  lamb 
into  the  brachial  vein  of  the  patient  at  the  bend  of  the  elbow. 
Immediate  improvement  was  noticed,  and  sixteen  days  after  the 
operation  the  patient  was  able  to  sit  up. 

When  the  haemorrhage  is  so  profuse  as  to  endanger  life,  von 
Ziemssen0  recommends  enemata  of  ice- water  and  injections  of  blood 
or  of  salt-water. 

a  Glasgow  Med.  Journal.     May,  1869. 

b  Sajous'  Annual  of  the  Univ.  Med.  Sciences.     1891.     Yol.  I.     H.-54. 

0  Loc.  cit.     1888.     Vol.  I.,  page  261. 


ENTERIC    FEVER.  471 

Opinions  are  not  unanimously  in  favour  of  ergot  as  a  styptic  in 
haemorrhage  from  the  bowels.  Dr.  James  Little,  who  was  pro- 
bably the  first  physician  in  Ireland  to  recommend  it,  has  long  since 
abandoned  its  use ;  and  Dr.  Walter  G.  Smith  also  considers  that 
its  efficacy  is  much  over-estimated  and  its  employment  is  of  ques- 
tionable advantage. 

All  authorities  are  agreed  that  the  first  and  chief  indication  in 
haemorrhage  is  absolute  rest,  and  this  is  secured  by  withholding 
food  for  some  hour3,  and  by  the  free  exhibition  of  opium,  internally 
or  as  a  hypodermic  injection  of  morphin. 

7.  Peritonitis. — When  this  serious  complication  is  localised, 
much  benefit  often  is  derived  from  the  application  of  even  a  single 
leech  over  the  ileo-caecal  valve. 

In  all  forms  of  peritonitis  the  great  object  to  be  secured  is 
absolute  rest,  and  to  secure  this  opium  must  be  given  with  a  free 
hand.  It  is  our  "sheet-anchor"  in  both  peritonitis  and  perfora- 
tion. To  an  adult  two  grains  of  solid  opium  may  be  given  at  once 
on  the  supervention  of  symptoms  of  peritonitis,  and  this  may  be 
followed  by  a  grain  every  second  or  third  hour,  uutil  slight  stupor 
ensues.  Nothing  is  more  remarkable  than  the  tolerance  of  opium 
displayed  by  the  unhappy  subject  of  peritonitis.  Murchison  states 
that  as  much  as  60  grains  has  been  taken  in  three  days  with  benefit. 
In  one  case  at  Cork-street  Fever  Hospital,  I  gave  quite  a  young  girl 
no  less  than  13  grains  in  24  hours  without  any  sign  of  narcotism. 
In  some  of  these  cases,  part  of  the  opium  may,  no  doubt,  be  rejected 
by  vomiting.  When  the  stomach  is  irritable,  hypodermic  injec- 
tions of  morphin  should  be  substituted  for  doses  of  opium  by  the 
mouth.  Murchison  insisted  that  the  opium  should  be  given  alone, 
and  not  in  combination  with  calomel,  which  brings  down  more  bile 
into  the  lower  bowel  and  so  excites  peristaltic  action.  By  far  the 
best  plan  is  simply  to  give  a  tiny  pilule  consisting  solely  of  one 
grain  of  opium. 

The  accompanying  pain  and  tension  of  the  abdomen  must  be 
relieved  by  warm  fomentations,  bran  poultices,  and  turpentine 
epithems ;  or,  still  better,  by  the  use  of  the  ice-bladder  or  ice- 
poultice.  


"472  .ENTERIC   FEVER. 

The  only  food  and  stimulant  should  be  a:  tablespoonful  of 
milk  and  of  iced  brandy  and  water,  given  alternately  every  half 
hour.      '     .     ; 

Should  the  patient's  life  be  spared,  we  must  beware  of  interfering 
with  the  constipation  induced  by  the  opium.  :  Far  better  to  leave 
the  bowels  to  themselves  than  to  run  the  terrible  risk  of  setting  up 
another,  and  probably  fatal,  attack  6f  peritonitis.  "  No  harm  will 
be  done,"  says  Liebermeister,  ''if  a  week,  or  even  two  or  three 
weeks,  pass  without  any  movement  of  the  bowels.  Not  until  later, 
when  all  evidences  of  peritonitis  have  disappeared,  will  it  be  per- 
missible to  use  a  small  htkewarm  enema  for  the  purpose  of  empty- 
ing the  rectum  of  the  hard  faecal  matters  it  often  contains."  i 

8.  Perforation. — Although  all  treatment  in  this  deadly  acci- 
dent is  only  a  forlorn  hope,  we  are  bound  to  save  life  if  possible, 
and  so  the  measures  just  recommended  in  peritonitis  should  be 
carried  out.  In  addition,  when  the  symptoms  of  perforation  are 
followed  by  great  abdominal  distension,  E.  Friedrich,a  Stein,b  and 
others  have  recommended  that  the  intestinal  and  peritoneal  gases 
should  be  drawn  off  by  paracentesis. 

Shall  laparotomy  be  performed  for  intestinal  perforation  in  enteric 
fever  ?  This  question  was  answered  in  the  affirmative  by  Leyden, 
of  Berlin,  on  May  24,  1884. 

At  the  Annual  Meeting  of  the  American  Surgical  Association, 
1 888,  Dr.  J.  Ewing  Mears,c  of  Philadelphia,  read  a  paper  on  the 
surgical  treatment  of  perforation  of  the  intestine  in  typhoid  fever. 
He  had  carefully  searched  current  medical  literature  up  to  date  and 
found  only  four  cases  of  surgical  interference  in  perforating  typhoid 
ulcer,  in. all  of  which  a  fatal  result  had,  unfortunately,  occurred. 
The  cases  were  operated  on  by  Prof.  Kussmaul,  of  Strassburg ;  Mr. 
T.  H.  Bartleet,  of  Birmingham ;  Dr.  R.  B.  Bontecou,  of  Troy, 
N.  Y. ;  and  Dr.  T.  G.  Morton,  of  Philadelphia.  The  following 
propositions  and  suggestions  were  offered  : — 1.  Surgical  interference 

*Prag.  Vierteljahrs.  fur  prakt.  Heilhunde.     1868.     c.  11. 
b  Deutsch.  Arch,  fiir  Min.  Med.     1869.     VI.,  page  454. 

c  Philadelphia  Medical  News.     September  29,  1889,  page  358;  and  Braith- 
waite's  Retrospect  of  Medicine.     Vol.  XCIX.,  page  24.     January-June,  1889.; 


ENTERIC   FEVER.  273 

is  not  justifiable  and  should  not  be  instituted  in  cases  of  typhoid 
fever  in  which  perforation  occurs  when  the  infective  process  is  at 
its  height.  2.  In  mild  cases  of  the  disease  in  which  the  pyrexia 
has  not  been  of  high  grade,  and  in  which  perforation  occurs  at  the 
end  of  the  third  week,  or  later  when  the  stage  of  convalescence  is 
fully  pronounced,  laparotomy  may  be  performed.  Surgical  inter- 
ference in  cases  of  this  character  is  advocated  with  the  hope  that  if 
the  method  of  operation  suggested  by  Lucke — laparotomy  with  the 
creation  of  an  artificial  anus — be  adhered  to,  success  may  be 
attained.  3.  Rapidity  of  operation  will  be  an  essential  factor  in 
the  achievement  of  success,  through  which  prolonged  exposure  of 
the  cavity  will  be  avoided  and  shock  greatly  lessened. 

The  statistics  of  the  operation  are  as  follows : — 

1884  (Sept.) — Mikulicz:  4  cases,  with  one  recovery;  though, 
unfortunately,  the  diagnosis  is  doubtful. 

1885. — Lucke  :  resection  ;  death. 

188(5. — Escher :  1  case;  recovery;  but  the  case  is  regarded  by 
Louis  as  one  of  appendicitis. 

1886. — Greig  Smith  :   1  case;   doubtful  diagnosis;  death. 

1886. — Bartleet:  1  case;  death. 

1887. — Bontecou:   lease:  death. 

1887. — Morton:  lease;  death.      - 

.1889. — Bontecou:  lease;  death. 

1889. — Senn :  volvulus  and  perforation,  1  case;  death. 

1889. — Hahn  :  2  cases  ;  death. 

1890. — Kimura:  1  case  ;  death. 

To  these  fifteen  cases  are  to  be  added  that  of  Taylor,  1891,  and 
three  reported  in  the  Medical  News  for  Saturday,  November  21, 
1891,  by  Weller  Van  Hook,  A3.,  M.D.,  Professor  of  Surgical 
Pathology  and  Bacteriology,  College  of  Physicians  and  Surgeons  ; 
Professor  of  Surgery,  Chicago  Post-Graduate  Medical  College ; 
Surgeon  to  Cook  County  and  Chicago  Charity  Hospitals.  One  of 
Dr.  Van  Hook's  cases  recovered,  making  in  all  19  recorded  laparo- 
tomies, with  4  recoveries. 

Dr.  Van  Hook,  in  his  paper,  to  which  I  owe  many- of  the  fore- 
going particulars,  arrives  at  the  following  conclusions,: — 


474  ENTERIC    FEVER. 

1.  There  is  no  rational  treatment  for  perforation  in  the  course 
of  typhoid  fever,  except  laparotomy. 

2.  The  indication  for  laparotomy  when  perforation  occurs  in 
typhoid  fever  is  imperative. 

3.  The  only  contra-indication  is  a  moribund  condition  of  the 
patient. 

4.  Collapse  is  often  at  least  temporarily  relievable  by  hot  peri- 
toneal flushing. 

5.  The  stage  of  the  fever  is  not  to  be  considered  as  an  indication, 
or  as  a  contra-indication,  for  laparotomy. 

6.  The  severity  of  the  typhoid  fever  alone  is  not  a  contra-indica- 
tion. 

7.  Early  laparotomy  offers  the  most  hope. 

8.  The  symptoms  of  peritonitis  should  not  be  awaited  before 
operating. 

9.  In  taking  charge  of  all  typhoid  fever  patients,  it  is  the 
physician's  duty  to  be  ready,  in  case  of  perforation,  to  perform 
laparotomy. 

10.  The  published  statistics  of  laparotomy  for  this  condition  are 
strongly  in  favour  of  operation. 

11.  The  technique,  though  not  complicated,  demands  much 
thoughtfulness,  acquired  dexterity,  great  rapidity,  and  thorough- 
ness. 

Viewing  the  hopelessness  of  treating  perforation  successfully  by 
either  medical  or  surgical  methods,  we  may  well  say  "  Prevention 
is  better  than  cure."  "Recollect,"  said  Sir  Dominic  Corrigan,"a 
u  with  these  ulcers  or  diseased  follicles,  how  thin  a  layer  of  serous 
membrane  literally  stands  as  the  barrier  between  life  and  death  in 
this  disease,  whether  the  death  result  from  haemorrhage  or  from 
perforation ;  and  that  a  purgative  or  an  article  of  diet  injudiciously 
exhibited  may  at  any  moment  cause  the  one  or  the  other.  There 
is,  perhaps,  no  other  disease  in  which  recovery,  and  even  life, 
depend  so  much  on  attention  to  details  of  treatment,  and  on  steadi- 
ness in  withholding  officious  interference,  no  less  than  in  judicious 
management." 
a  Lectures  on  the  Nature  and  Treatment  of  Fever.     1853.     Lect.  X.    Page  99. 


475 


CHAPTER  XLVIII. 

The  Curative  Treatment  of  Enteric  Fever — 

Concluded. 

Managkment  in  Convalescence. 

Unwonted  Exertion,  exposure  to  cold,  indiscretion  in  diet  are  all  to  be 
avoided. — Treatment  of  :  Constipation,  atonic  diarrhoea. — Reduce  stimulants 
day  by  day. — Solid  Food  :  anecdote  narrated  by  Dr.  Stokes. — Rules  for  giving 
Solid  Food:  Fish,  boiled  or  broiled — not  fried. — Dietaries  recommended  by 
Hilton  Fagge,  Murchison,  von  Ziemssen,  Niemeyer,  F.  Woodbury,  Hutchinson, 
Lauder  Brunton. — Medicines  in  Convalescence. — Change  of  Air. — Pro- 
longed Rest. 

In  probably  no  other  acute  disease — scarlatina  and  rheumatic  fever 
not  even  excepted — is  there  more  need  than  in  enteric  fever  for 
continued  watching  and  skilful  handling  on  the  part  of  the  physi- 
cian far  on  into  the  period  of  convalescence. 

Each  step  in  the  management  of  the  patient  in  his  progress 
towards  health  demands  most  anxious  consideration,  and  should  be 
taken  only  at  the  instance,  or  with  the  sanction,  of  the  physician. 

Long  after  the  febrile  movement  of  enteric  fever  has  drawn  to  a 
■close,  unwonted  exertion,  exposure  to  cold,  or  indiscretion  in  diet 
may  again  place  life  in  jeopardy.  Hence  it  is  that  the  time  for 
leaving  the  sick-bed,  and  then  the  sick-chamber,  for  going  out  of 
doors,  and  for  taking  solid  food,  must  all  be  arranged  for  the 
patient— not  by  the  patient. 

Remember  how  indefinite  is  the  duration  of  the  process  known 
as  cicatrisation.  No  one  can  tell  in  a  given  case  to  what  an  extent 
Peyer's  patches  are  involved,  and  again — as  we  have  seen — cica- 
trisation may  be  completed  in  one  portion  of  the  bowel  ere  it  has 
well-nigh  begun  in  another.  Under  these  circumstances,  it  is 
obvious  that  the  strictest  caution  should  be  observed  in  allowing  a 
convalescent  from  enteric  fever  to  exert  himself,  in  the  administra- 
tion of  aperients,  and  in  ordering  a  change  of  diet. 


476  ENTERIC    FEVER. 

In  the  first  place,  evening  observations  on  the  temperature  should 
be  continued  for  at  least  two  weeks  after  convalescence  has  com- 
menced. In  this  way,  we  can  usually  gauge  with  approximate 
certainty  the  favourable  or  unfavourable  nature  of  the  patient's 
progress  ;  while  timely  warning  is  given  that  the  diet  is  disagreeing 
or  that  a  relapse  is  impending. 

Constipation,  again,  is  frequently  most  troublesome  even  after 
attacks  in  which  diarrhoea  has  been  a  prominent  symptom.  It 
may  sometimes  be  overcome  by  varying  the  food,  or  the  times  at 
which  food  is  given.  In  other  cases,  it  will  be  sufficient  to  give 
the  glycerine  and  castor  oil  draught  already  mentioned  (see  page 
463),  or  to  administer  a  simple  enema  every  day  or  every  second 
day.  Another  safe  remedy  is  the  sipping  of  a  tumblerful  of  cold, 
luke-warm,  or  hot  water  in  the  morning  fasting.  Apart  from  its 
diluent  and  laxative  effects,  water  sipped  in  this  way  stimulates 
both  the  heart  and  the  liver.  Dr.  Lauder  Brunton,  F.R.S.,  in  his 
very  interesting  work  on  "  Disorders  of  Digestion," a  says  that 
Kronecker  has  discovered  that  the  act  of  swallowing  seems  to 
remove  entirely  the  inhibitory  action  of  the  vagus  upon  the  heart, 
for  the  time  being,  so  that  the  pulse  becomes  exceedingly  rapid. 
The  extent  to  which  this  occurs  will  hardly  be  credited  by  anyone 
who  has  not  tried  the  experiment.  In  Dr.  Brunton's  own  case,  he 
found  that  sipping  half  a  wineglassful  of  water  would  raise  his 
pulse  from  76  to  considerably  over  100.  So  that,  in  fact,  a  glass 
of  cold,  water,  slowly  sipped,  will  stimulate  the  heart  as  much  as, 
or  more  than,  a  glass  of  brandy  swallowed  at  a  draught. 

Dr.  Brunton  proceeds  to  showb  that  sipping  not  only  has  this 
powerful  effect  upon  the  heart,  but  that  it  has  also  a  similar  effect 
upon  the  liver.  It  has  been  shown  by  Zawilski*  that  water,  slowly 
sipped,  hot  only  increases  the  amount  of  bile  secreted,  but  causes 
it  to  be  secreted  under  higher  pressure,  so  that  if  any  slight 
obstruction  should  be  present  in  the  bile-ducts,  it  will  be  over- 
come, and  the  bile  will  flow  freely  into  the  bowel. 

"London:  Macmillan  &  Co.     1886.     Page  11. 

b  Loc.cit.     Page  73. 

c  Sitzungsbericht  der  wiener  Akad.     1877.     Mat.  nat-.  Abtg.     P>d.  IV.,  p.  73: 


ENTERIC    FEVER.  I  i  7 

•  When,  on  the  other  hand,  diarrhoea  persists  through  convales- 
cence; the  patient  should  he  kept  in  bed.  Murchison  advises 
that  this  atonic  diarrhoea  should  be  treated  by  astringents  and 
tonics  such  as  acetate  of  lead,  sulphate  of  copper,  or  nitrate  of 
silver.  At  the  same  time  he  draws  attention,  with  approval,  to 
a  remark  of  Tronsseaua,  that  when  there  is  great  emaciation, 
especially  in  cases  which  have  been  treated  on  too  lowering  principles, 
vomiting  and  purging  during  convalescence  may  be  of  a  purely 
nervous  character,  and  sometimes  are  at  once  relieved  by  solid  food. 

Hilton  Fagge  wisely  observes  that  "  stimulants  should  be  at 
once  diminished  on  the,  subsidence  of  fever,  and  in  many  cases 
it  is  desirable  to  substitute  an  ounce  or  two  of  wine  twice  or 
thrice  a  day  for  brandy  at  frequent  intervals.  With  young  patients, 
however,  after  a  favourable  attack  there  is  often  no  need  for 
stimulants  or  drugs." 

I  consider  that  this  is  sound  advice.  A  grave  responsibility 
rests  on  a  physician  who  does  not  daily  revise  his  patients'  allow- 
ance of  stimulants  when  recovering  from  aeute  illness.  There 
can  be  no  doubt  that  habits  of  intemperance  in  too  many  instances 
date  back  to  a  time  when  a  good-natured  or  a  neglectful  physician 
allowed  his  patient  to  remain  day  after  day  or  week  after  week 
on  an  allowance  of  wine  or  spirit,  for  the  giving  of  which  there 
was  no  warrant. 

Another  rule  to  be  stringently  carried  out  is,  that  on  no  account 
should  alcoholic  stimulants  be  taken  without  food — it  maybe  only i 
a  biscuit;  !  I  hold  that  most  fever  convalescents  are  better  without 
alcoholic  stimulants— rrthey  have  had  poison  enough  in  their  bodies— r 
but,  if  stimulants  are  given,  they  should  be  prescribed  as  medicine 
and  not  a  la  carte  blanche. 

All  modern  authorities  are  agreed  that  the  greatest  caution  must 
be  exercised  in  permitting  the  typhoid  convalescent  to  partake  of 
solid  food,  and  particularly  butcher's  meat.  Stokes,  indeed,  tells  a 
graphic  and  amusing  story,  in  his  "  Lectures  on  Fever,"b  of  a  lady,. 

a  Clinique  Med.  de  V Hotel  Dieu  de  Paris.  1865.  Tome  I.,  page  264.  See 
above,  page'  399.  <  '    '     .  •    •        „ : : 

b  Edition  of  1874.     Pages  332,  et  seq.  ,;,,.,'     ' 


478  ENTERIC   FEVER. 

recently  married,  who  was  violently  delirious  on  the  12th  or 
13th  day  of  "extremely  severe  petechial  fever" — that  is,  be  it 
noted,  typhus,  not  typhoid — and  in  her  delirium  craved  for  "  a 
rump  of  beef  and  cabbage,"  which  were  being  cooked  in  the  kitchen, 
and  the  odour  of  which  filled  the  house.  Her  sister,  who  was 
nursing  her,  believing  she  was  dying,  resolved  to  gratify  her  wish 
from  the  feeling  that  it  was  right  to  accede  to  the  request  of  a  dying 
person.  She  proceeded  to  the  kitchen,  and  brought  up  a  large 
mess,  steaming  hot,  to  the  lady's  bedside,  when  the  patient  de- 
voured it  with  great  avidity.  Shortly  afterwards  her  husband 
came  in,  and  was  told  what  had  happened.  He  became  terrified, 
and  sent  for  physicians  in  every  direction.  Four  or  five  assembled, 
each  of  whom  had  his  own  suggestion  to  offer.  At  length  the  late 
Dr.  Harvey,  then  Physician-General,  joined  in  the  consultation. 
On  proceeding  to  the  lady's  bedside,  the  consultant-in-chief,  Dr. 
Harvey,  found  the  patient  asleep.  She  was  reported  to  him  to  be 
comatose.  His  advice  was  :  "  I'd  let  her  sleep  it  out."  She  did 
sleep  it  out,  and  in  the  course  of  some  hours  awoke  much  better. 
Her  recovery  was  perfect.  Dr.  Stokes,  in  narrating  this  anecdote, 
was  careful  to  show  that  he  did  not  do  so  with  the  object  of  in- 
ducing physicians  to  feed  their  patients  with  salt  beef  and  cabbage 
in  fever. 

"  No  solid  food,"  says  Hilton  Fagge,  "  should  be  given  for  a 
fortnight  after  fever  and  diarrhoea  have  ceased.  The  patient  will 
bitterly  complain  of  the  restriction  ;  but  if  the  physician  has  once 
lost  a  patient  from  perforation  during  convalescence  he  will  be 
inexorable  ever  after.  Progress  to  health  after  this  disease  must 
be  slow  if  it  is  to  be  sure." 

To  the  same  effect  Murchison  writes  :  "  Notwithstanding  the 
cravings  of  the  patient's  appetite,  the  diet  must  be  at  first  restricted 
to  such  articles  as  milk,  eggs,  farinacea,  custards,  light  puddings, 
beef-tea,  chicken-tea,  or  calf's  foot  jelly.  Meat  ought  not  to  be 
allowed  for  at  least  seven  days  after  the  cessation  of  pyrexia,  and 
not  even  then  if  there  be  any  signs  of  intestinal  disturbance ;  and 
before  meat  is  given  it  is  well  to  try  for  a  day  or  two  a  piece  of 
boiled  sole,  smelt,  or  whiting." 


ENTERIC    FEVER.  479 

In  reference  to  the  last-mentioned  recommendation,  I  may  state 
that  a  fish  diet  does  not  always  agree  with  a  fever  convalescent. 
Indeed,  it  sometimes  appears  to  produce  poisonous  effects,  perhaps 
owing  to  the  formation  of  one  of  the  alkaloids  produced  by  the 
decomposition  of  proteid  substances,  to  which  Professor  Selmi,  of 
Bologna,  gave  the  name  of  ptomai'ns,  by  which  they  are  now  known. 
The  result  may  be  a  recrudescence  of  the  pyrexia.  I  have  known 
this  to  occur  in  more  than  one  case  after  enteric  fever — the  fish  eaten 
being  a  sole  apparently  in  good  condition.  "  Of  all  fish,"  writes 
F.  W.  Pavy,a  "  the  whiting  may  be  regarded  as  the  most  delicate, 
tender,  easy  of  digestion,  and  least  likely  to  disagree  with  a  weak 
stomach.  It  is  sometimes  styled  the  chicken  of  the  fish  tribe.  The 
haddock  is  somewhat  closely  allied,  but  has  a  firmer  texture,  and  is 
inferior  in  flavour  and  digestibility.  The  sole  is  a  tender  and 
digestible  fish.  It  also  has  a  delicate  flavour,  and  deservedly 
enjoys  a  high  reputatiou  as  an  article  of  food  for  the  invalid.  The 
flounder  is  light  and  easy  of  digestion,  but  insipid.  In  all  cases 
where  fish  is  required  for  a  weak  stomach,  either  boiling  or 
broiling  should  constitute  the  process  of  cooking.  Frying  is 
objectionable  on  account  of  the  fatty  matter  used  rendering  the 
fish  rich  and  more  indigestible." 

Von  Ziemssen,  in  his  "  Lectures  on  the  Treatment  of  Typhoid 
Fever,"  to  which  reference  has  before  been  made,  expresses  the 
opinion  that  the  diet  of  convalescence  should  follow  the  usual  diet 
of  health  with  certain  modifications.  The  return  to  solid  food 
should  be  as  follows  : — First  breakfast :  tea,  with  biscuit  and  one 
soft-boiled  egg.  Second  breakfast :  100  grammes  (3^  ozs.)  of  finely 
minced  raw  bacon  with  wheat  bread  crumbs.  Noon  :  150  grammes 
(5  j  ozs.)  of  pigeon,  young  chicken,  or  partridge  finely  minced  in 
soup.  Later  on  this  may  be  given  in  combination  with  a  mild 
sauce  and  mashed  potato,  wine  or  beer  being  taken  as  a  beverage. 

In    the    afternoon :    tea    with    biscuit   or   cakes.    For  supper : 

"  mush," — that  is,  Indian  corn  porridge — and  milk,  two  soft  eg^s 

and  some  raw  bacon.     This  may  soon  be  followed  by  calves'  feet 

for  breakfast,  then  an  English  broiled  beefsteak,  mutton  and  pre- 

0  A  Treatise  on  Food  and  Dietetics.     1874.     Page  156. 


480  ENTERIC    FEVEK. 

serves,  and  In  the  evening  some  strengthening  soup'and  some  beer. 
At  this  stage,  when  the  patient  thinks  of  nothing  but  eating, 
Something  hew  in  the  way  of  food  must  be  given  daily. 

i  "  It  is  best,"  says  Niemeyer,a  "  to  let  the  patient  eat  frequently, 
but  only  a  little  food  at  a  time,  so  that  the  slight  amount  of  gastric 
juice  secreted  by  the  convalescents  may  suffice  for  its  complete 
digestion.  All  indigestible  food,  which  forms  large  amounts  of 
faeces,  should  be  strictly  forbidden.  An  insignificant  indigestion,  a 
moderate  diarrhoea,  or  slight  vomiting,  should  be  regarded  as.a-very 
dangerous  occurrence,  because  it  may  induce  perforation  of  an 
ulcer  that  has  not  yet  cicatrised." 

¥.  Woodbury6  considers  the  different  preparations  of  coca  espe- 
cially valuable  in  convalescence  from  enteric  fever,  being  superior 
to  digitalis,  for  instance,  in  not  having  a  tendency  to  cause  diarrhoea. 

'  Hutchinson0  finds  a  too  early  return  to  solid  food  prejudicial  to 
the  patient.  He  continues  the  exclusive  milk  diet  for  three  or  four 
days  after  complete  defervescence,  or  adds  only  animal  broths. 
Then  he  gives  soft-boiled  eggs,  the  juice  of  underdone  meat,  with 
milk  toast  and  other  farinaceous  articles.  At  the  end  of  a  week- 
the  soft  parts  of  oysters  and  fish  are  added  to  the  dietary;  at  the 
end  of  ten  days,  the  light  meat  of  broiled  chicken ;  at  the  end  of - 
two  weeks,  butcher's  meat.  All  these  articles  of  food  are  given  in 
small  quantities  at  first.  ,     <,: 

■1  I  close  this  subject  of  diet  in  convalescence  after  enteric  fever 
with  a  quotation  from  Dr.  Lauder  Brunton's  Lettsomian  Lectures1 
on .-"  Disorders  of  Digestion,"  delivered  before  the  Medical  Society 
of  London  in  January  and  February,  1885: — '*The  palate,"  he 
says,  "  like  the  appetite,  sometimes  makes  demands  which  are  a*pt 
to  be  misconstrued.  As  the  late  Professor  Laycock  observed, 
patients  recovering  from  a  severe  illness  not  unfrequently  have  a 
strong  desire  for  salt  herrings,  pork,  or  ham,  things  which  would 
be  almost  certain  to  disagree   with   them   if  their  appetite  were 

a  A  Textbook  of  Practical  Medicine.  -  Revised  Edition.  1880.  Vol.  II., 
page  655. 

6  Sajous'  Annual  of  the  Universal  Medical  Sciences.     1890.     Vol.  I.     H.-52. 
c  Loc.  cit.    -  .  . ,  >    '    •• 


ENTERIC:  FEVER.  481 

indulged.  But  the  fact  is  that  the  patients  do  not  want  the  pork 
or  herring;  what  they  really  desire  is  salt,  and  they  crave  for  these 
articles  because  they  contain  salt.  If  salt  be  given  to  them  in  tin- 
form  of  a  mixture,  their  appetite  is  appeased,  and  the  harm  is 
avoided  which  the  herring  or  ham  might  have  caused." 

Few,  if  any,  medicines  are  required  in  convalescence.  But  if 
the  patient's  state  remains  unsatisfactory — if  his  progress  towards 
recovery  "hangs  fire" — when,  in  a  word,  convalescence  is  slow, 
Murchison  recommends  "  quinine,  the  mineral  acids,  iron,  cod-oil, 
and  change  of  air."  The  last  is,  to  my  mind,  by  far  the  most  im- 
portant of  all — particularly,  should  the  patient  have  passed  through 
his  illness  in  the  house  which  gave  it  to  him  owing  to  structural 
faults  and  defective  drainage.  Some  years  ago  a  young  lady, 
almost  dying  of  asthenia  and  anaemia  after  a  protracted  typhoid 
fever,  was — by  the  advice  of  one  of  the  first  consulting  physicians 
in  Dublin — sent  away  in  a  carriage  from  one  of  the  squares  in 
Dublin  only  as  far  as  the  suburb  of  Sandymount,  two  miles  distant. 
The  result  was  that  she  immediately  began  to  improve,  and  ulti- 
mately made  a  rapid  and  complete  recovery. 

Lastly,  several  months  should  be  allowed  to  elapse  before  the 
convalescent  resumes  his  usual  avocations — at  least,  if  they  are 
such  as  to  put  a  strain  upon  either  his  bodily  or  his  mental  powers- 
It  often  takes  six  months  or  even  a  year  before  these  are  thoroughly 
restored.  "  There  is  no  disease,"  observes  Hilton  Fagge,  "  not  even 
rheumatic  fever,  in  which  it  is  so  important  for  the  patient  to  have 
a  long  period  to  recover  his  strength  before  returning  to  his  ordi- 
nary duties." 

Should  these  rules  be  carried  out,  one  would  be  justified  in  anti- 
cipating for  the  convalescent  a  "  new  lease  of  life,"  with  a  braced 
and  invigorated  muscular  system,  and  a  healthy,  clear,  and  active 
brain. 


2  i 


482 


CHAPTER  XLIX. 
Infection  and  Immunity. 

Klemperer  and  Klemperer's  researches  on  Infection  and  Immunity. — Case 
of  acute  fibrinous  pneumonia. — Pneumotoxms  and  anti-pneumotoxins.— Dr. 
A.  C.  Abbott's  conclusions. 

I  have  stated,  on  page  22,  that  the  question  of  immunity  is  still 
undecided.  The  most  recent  and  valuable  contribution  to  the 
literature  of  the  subject  is  a  paper  by  Klemperer  and  Klemperer, 
in  Nos.  34  and  35  of  the  Berliner  klin.  Wochenschrift  for  1891,  on 
the  nature  of  the  infection  in  acute  fibrinous  pneumonia.  For  the 
following  abstract  of  their  researches  I  am  indebted  to  an  excellent 
review  (by  Dr.  A.  C.  Abbott,  First  Assistant  in  the  Department  of 
Hygiene  of  the  University  of  Pennsylvaniaa),  of  the  experimental 
work  in  connection  with  immunity  and  infection  carried  on  during 
the  past  few  years.  This  review  was  contributed  to  the  number  of 
the  Practitioner  for  December,  1891. 

Klemperer  and  Klemperer's  experiments  bore  entirely  upon  the 
nature  of  the  infection  in  acute  fibrinous  pneumonia  and  have  shed 
much  light  upon  some  of  the  obscure  features  of  that  disease.  They 
found  but  little  difficulty  in  affording  immunity  to  animals  that  are 
otherwise  susceptible  to  the  pathogenic  action  of  the  organisms 
concerned  in  the  production  of  this  disease,6  by  the  introduction 
into  their  tissues  of  the  products  of  growth  of  the  organisms  from 
which  the  latter  had  been  separated.  The  immunity  thus  produced 
is  seen  in  some  cases  to  last  as  long  as  six  months ;  again  it  is  seen 
to  disappear  suddenly  in  a  way  not  to  be  explained.  It  was  seen 
in  one  case  to  be  hereditary. 

a  See  also  Medical  News,  Philadelphia,  November  7,  1891. 

b  Animals  do  not,  as  a  rule,  present  the  pneumonic  changes  seen  in  human 
beings.  The  introduction  of  the  diplococcus  of  pneumonia  into  their  tissues 
results,  in  the  case  of  susceptible  animals,  in  the  production  of  septicaemia. 


INFECTION   AND    IMMUNITY.  4K3 

The  energy  of  the  substance  which  has  the  power  of  affording 
immunity  was  seen  to  be  very  much  increased  by  subjecting  it  to 
temperatures  somewhat  higher  than  that  at  which  it  was  produced 
by  the  bacteria — 37*5°  C.  (99-4"  F.)  Klemperer  and  Klemperer 
found  that  if  this  substance  was  heated  to  a  temperature  of  from 
41°  to  42°  C.  (105-8°  to  107'6"  F.)  for  three  or  four  days,  or 
to  60°  C.  (140"  F.)  for  from  one  or  two  hours,  intravenous 
injection  was  followed  by  complete  immunity  in  from  three 
to  four  days;  whereas,  if  the  unwarmed  material  was  used,  im- 
munity did  not  appear  until  fourteen  days,  and  then  only  after 
the  employment  of  relatively  large  amounts.  Moreover,  when  the 
previously  heated  products  are  introduced  into  the  circulation  of 
the  animal,  the  systemic  reaction  is  of  but  short  duration,  but  if 
the  unwarmed  substance  is  employed,  immunity  is  manifest  only 
after  the  appearance  of  considerable  elevation  of  temperature, 
which  lasts  for  a  long  time. 

In  explanation  of  these  differences,  they  suggest  that,  in  the 
latter  case,  the  high  fever  that  is  seen  to  occur  in  the  animal  may 
serve  to  replace  the  warming  to  which  the  product  had  not  pre- 
viously been  subjected,  and  which  is  necessary  before  the  products 
of  the  bacteria  are  in  a  position  to  bring  about  the  condition  of 
immunity.  They  claim  that  the  bacterial  products  employed  in 
producing  immunity  in  this  case  are  not,  in  reality,  the  immunity- 
affording  substance,  but  that  they  are  only  the  agents  that  bring 
about  in  the  tissues  of  the  animals  alterations  that  result  in  the 
production  of  another  body  that  protects  the  animal. 

In  support  of  this,  their  argument  is  that  several  days  are 
necessary  for  the  production  of  immunity  by  the  introduction 
into  the  animal  of  the  bacterial  products;  whereas,  if  the  blood- 
serum  of  this  animal,  which  is  now  protected,  be  introduced  into 
the  circulation  of  another  animal,  no  such  delay  is  seen,  but 
instead,  the  animal  is  forthwith  protected.  In  the  former  case 
the  actual  protecting  body  must  first  be  manufactured  by  the 
tissues  ;  whereas,  in  the  second  it  is  already  prepared,  and  is  intro- 
duced as  such  into  the  second  animal. 

The  serum  of  immunified  animals  is  not  only  capable  of  rendering 


484  INFECTION    AND    IMMUNITY. 

other  animals  immune,  but  moreover  possesses  curative  powers 
when  the  disease  is  already  in  progress.  The  serum  of  immuni- 
fied  animals,  when  injected  into  the  circulation  of  animals  in  which 
this  form  of  infection  was  in  progress,  and  in  which  there  was  a 
body-temperature  of  from  40-4°  to  41°  C,  reduced  this  temperature 
•to  normal  (37'5°  C.)  in  twelve  consecutive  experiments  during  the 
first  twenty-four  hours  following  its  employment. 

Klemperer  and  Klemperer  explain  that  the  crisis  seen  in  pneu- 
monia in  human  beings  occurs  at  the  moment  when  the  poisonous 
products,  manufactured  by  the  bacteria  located  in  the  lungs,  are 
present  in  the  circulation  in  amounts  sufficient  to  call  forth  in  the 
tissues  the  reactive  change  that  results  in  the  production  of  the 
antidotal  substance  which  has  the  power  of  rendering  the  poisons 
inert. 

At  the  time  of  the  crisis  in  pneumonia  the  bacteria  themselves 
are  in  no  way  affected.  They  remain  in  the  lungs,  and  can  be 
detected  in  full  vigour  and  virulence,  in  the  sputum  of  patients 
a  long  time  after  the  disease  is  cured.  They  have  lost  none  of 
their  power  of  producing  poisonous  products,  and  still  possess 
their  original  pathogenic  relations  toward  susceptible  animals. 
It  is  only  after  the  crisis  that  their  poisons  are  neutralised  by 
this  antidotal  proteid  which  has  been  eliminated  by  the  cells  of  the 
tissues,  and  as  this  occurs  the  systemic  manifestations  gradually 
disappear.  Klemperer  and  Klemperer  isolated,  from  the  cultures 
of  the  diplococcus  of  pneumonia,  a  proteid  body  which  is  the  agent 
concerned  in  producing  the  tissue-changes  that  result  in  the  forma- 
tion of  the  protecting  substance.  They  likewise  isolated  from  the 
serum  of  immunified  animals  a  proteid  which  possesses  the  same 
powers  as  the  serum  itself — of  affording  immunity  and  of  curing 
the  disease.  The  poisonous  bacterial  product  they  propose  to  call 
pneumotoxin ;  the  protecting  body,  anti-pneumotoxin. 
,  After  obtaining  these  results  upon  the  lower  animals  they 
directed  their  attention  to  human  beings,  and  found  that  by  the 
subcutaneous  application  of  the  serum  of  immunified  animals  to 
patients  suffering  from  acute  fibrinous  pneumonia  the  results  were 
in  the  main  promising.     They  found  that  while  healthy  individuals 


INFECTION    AND    IMMUNITY.  485 

and  those  suffering  from  other  forms  of  disease  presented  no  systemic 
reaction  after  the  injection  of  the  scrum,  in  six  cases  of  pneumonia 
in  which  the  serum  was  employed  there  was  a  remarkable  fall  of 
temperature  and  slowing  of  the  pulse  within  the  first  twelve  hours 
after  it  was  injected.  In  four  of  these  cases  the  temperature  fell 
to  normal,  but  rose  again  after  six  hours.  In  two  cases  it  fell  to 
normal,  and  remained  at  that  point. 

It  would  appear  from  the  results  obtained  by  these  two  observers 
that  immunity  against  this  disease,  and  the  processes  concerned 
in  its  cure,  are  of  a  chemical  nature,  the  active  poisons  of  the 
organisms,  the  pneumotoxins,  being  neutralised  by  the  tissue- 
products,  the  anti-pneumotoxins. 

Results  upon  animals  in  general  analogous  to  those  of  Klem- 
perer  and  Klemperer  have  been  obtained  by  Emmerich  and 
Fowitzky.a 

In  the  light  of  these  experiments  the  hypothesis  advanced  by 
Buchner,  that  immunity  was  to  be  explained  by  reactive  changes 
in  the  integral  cells  of  the  body,  receives  considerable  support. 

As  a  result  of  his  very  critical  and  comprehensive  review  of  the 
modern  literature  of  the  subject,  Dr.  A.  C.  Abbott  arrives  at  the 
following  conclusions : — 

11  1.  That,  of  the  hypotheses  that  exist  for  the  explanation  of 
immunity,  that  which  assumes  acquired  immunity  to  be  due  to 
reactive  changes  on  the  part  of  the  tissues  has  received  the 
greatest  support. 

"  2.  That  immunity  is  most  frequently  seen  to  follow  the  intro- 
duction into  the  body  of  the  products  of  growth  of  bacteria  that 
in  some  way  or  other  have  been  modified.  This  modification  may 
be  artificially  produced  from  the  products  of  virulent  organisms 
and  then  introduced  into  the  tissues  of  the  animal ;  or  the 
organisms  themselves  may  be  so  treated  that  they  are  no  longer 
virulent,  so  that  when  introduced  into  the  body  of  the  animal  they 
eliminate  poisons  of  a  much  less  vigorous  nature  than  is  the  case 
when  they  possess  their  full  virulence. 

"3.  That  immunity  following  the  introduction  of  bacterial 
a  Emmerich  and  Fowitzky  :  Munch,  med.  Wochenschr.,  1891,  No.  32. 


48&  INFECTION    AND    IMMUNITY. 

products  into  the  tissues  is  not  the  result  of  the  permanent  presence 
of  these  substances  per  se  in  the  tissues,  or  to  a  tolerance  acquired 
by  the  tissues  to  the  poison,  but  is  probably  due  to  the  formation 
in  the  tissues  of  another  body  that  acts  as  an  antidote  to  the 
poisonous  substance. 

"  4.  That  this  protective  proteid  that  is  eliminated  by  the  cells 
of  the  tissues  need  not  of  necessity  be  antagonistic  to  the  life  of 
the  organisms  themselves,  but  in  some  cases  must  be  looked  upon 
more  as  an  antidote  to  their  poisonous  products. 

"  $.  That  in  the  serum  of  the  normal  circulating  blood  of  many 
animals  there  exists  a  body  that  is  capable,  outside  of  the  body,  of 
rendering  inert  bacteria  that,  if  introduced  into  the  body  of  the 
animal,  would  prove  infective. 

"  6.  That,  in  many  instances,  infection  may  be  looked  upon  as 
a  contest  between  the  bacteria  and  the  tissues,  carried  on  on  the 
part  of  the  former  by  the  aid  of  the  poisonous  products  of  their 
growth,  and  resisted  by  the  latter  through  the  agency  of  proteid 
bodies  normally  present  in  their  integral  cells. 

"  7.  That  when  infection  occurs  it  may  be  explained  either  by 
the  excess  of  vigour  of  the  bacterial  products  over  the  antidotal  or 
protective  proteids  eliminated  by  the  tissues,  or  to  some  cause  that 
has  interfered  with  the  normal  activity  and  production  of  these 
bodies  by  the  tissues. 

■■  "  8.  That  phagocytosis,  though  frequently  seen,  is  not  essential 
to  the  existence  of  immunity,  but  is  more  probably  a  secondary 
process;  the  bacteria  being  taken  up  by  the  leucocytes  oniy  after 
having  been  rendered  inert  through  the  normal  germicidal  activity 
of  the  serum  of  the  blood  and  other  fluids  of  the  body." 


INDEX    OF    SUBJECTS. 


Abdominal  pain,  469. 

typhus,  341. 
Abortive  enteric  fever,  405. 

typhus,  294. 
Abscesses,  101. 
Abschuppung,  27. . 
Absorbent  powders,  465. 
Absplitterung,  27. 

Accidental  erythema  in  enteric  fever,  374. 
fever,  2. 
rashes — in  enteric  fever,  371. 

smallpox,  76,  90,  99. 
Acetanilide,  459. 
Acids,  mineral,  49. 
Acme  or  fastigium,  25,  76. 
Acquired  immunity,  22,  24. 

predisposition  to  disease,  38. 
Act,  Public  Health  (England),  1875,  41. 

(Ireland),  1878,  38,  41,  46,  47. 
(Scotland),  41. 
Vaccination,  103,  109.  A 
Acute  desquamative  nephritis,  146,  170,  174,  175,  176,  189,  281,  290,  303,  401, 

enteric  fever,  407. 
"  Acute  furuncular  diathesis,"  85,  94,  191. 
haemophilia,  91,  92,  170,  470. 
parenchymatous  myocarditis,  178,  287. 

nephritis  146,  170,  174,  175,  176,  189,  281,  290,  303,- 
401. 
Adrianople,  inoculation  for  smallpox  at,  103. 
Adventitious  rashes  in  enteric  fever,  371. 
Adynamia,  242,  259,  461. 
Adynamic  measles,  142,  143. 

simple  fever,  235,  237. 
typhus,  264,  293. 


488  INDEX    OF    SUBJECTS. 

Aerobic  microbes,  15. 

^Etiology — of  small-pox,  70  ;  chickenpox,  125  ;  measles,  133  ;  scarlatina,  155  ; 

Kbtheln,  193  ;  erysipelas,  203  ;  febricula,  234  ;  typhus,  243,  253  ;  relapsing 

fever,  314  ;  enteric  fever,  345. 
Afebrile  enteric  fever,  407. 
Affusion,  cold,  56,  62,  451. 
Age  as  a  predisponent,  125,  135,  251,  316,  349. 
Ague,  19. 
Air  as  a  carrier  of  enteric-fever  poison,  357. 

fresh,  in  typhus,  308. 
Albumen,  fixed  and  circulating,  9. 
Albuminuria,  163,  177,  278,  381. 
Alcoholic  intemperance,  39,  42. 

stimulants  in  fever,  48,  58,  59,  120,  188,  223,  221,  310,  331,  440,  441, 
477. 
Amaurosis,  399. 

Ambient  air  for  cooling  fever  patient,  458. 
Amblyopia,  399. 

American  treatment  of  smallpox,  117. 
Amphibolic  stage  in  enteric  fever,  366,  394. 
Anabolism,  4. 
Anaemia,  416. 
Anaerobic  microbes,  15. 
Anaesthesia,  283. 
Anasarca,  177,  402. 
Angina  maligna,  168. 

pectoris  vaso-motoria',  170. 
Animal  heat,  theory  of,  4. 

kingdom,  thermal  nervous  system  in  the,  5. 
Ankle-clonus,  289. 
Anorexia,  211,  276. 
Anticipative  use  of  stimulants,  310. 
Antifebrin,  459. 
Antimony  in  enteric  fever,  443. 
Antipyresis,  53,  450,  458, 
Antipyretics,  52,  452,  458. 
Antipyrin,  459. 
Antiseptics,  31,  50,  114,  440. 
Antiseptic  treatment,  50,  114,  440. 
Anuria,  174,  176.  ' 

Aperients,  52. 
Aphonia,  81,  95,  280. 


INDEX  or  subjects.  489 

Apparatus  for  the  continual  bath,  Hebra's,  121. 

thermal,  5. 
Apyrexia,  24,  388. 
Apyrexial  enteric  fever,  407. 
Ardent  fever,  233,  235,  236. 
Areola  of  smallpox,  79. 

vaccina,  109,  111. 
Armentyphus,  39,  313. 
Army  Medical  Department,  339. 
Arsenic  in  enteric  fever,  443. 
Arterial  thrombosis,  290,  398. 
Ascites,  177. 
Asthenia,  416. 
Asthenic — measles,  142,  143. 
pneumonia,  296. 
simple  fever,  235,  237. 
Ataxia,  169,  181,  240,  259,  297,  461. 
Ataxic  symptoms  of  fever,  8,  61,  159. 

state,  58,  61,  62,  143,  260,  303,  329,  369,  376. 
scarlatina,  168  ;  typhus,  264,  293. 
Ataxo-adynamic  typhus,  293. 

enteric  fever,  461. 
Atonic  diarrhoea,  399. 
Atrophic  keratitis,  94,  122,  146,  171. 

furrow  in  nails,  272,  375. 
Attenuated  virus,  43,  103. 
Autochthonous  disease,  235,  355,  356. 
Autogenous  enteric  fever,  355,  356. 
Autotyphisation,  359. 
"  Autumnal  fever,"  340,  349. 
Axillary  bubo — of  vaccino-syphilis,  1 12. 

Bacillus  anthracis,  23,  357. 
coli  communis,  359. 
diphtherise,  168. 
malariae,  19; 

typhosus  (Eberth),  342,  352,  353,  354,  355,  356,  359,  360,  422,  447. 
Bacteria,  14,  216. 

classification  of,  15. 
Bacteriology — of  smallpox,  73  ;  of  varicella,  126  ;  of  measles,  134  ;  of  scarlatina, 
158,  192  ;    of  erysipelas,  203,  209  ;   of  typhus,  244 ;  of  relating  fever, 
318  ;  of  entsric  fever,  351. 


490  INDEX    OF   SUBJECTS. 

Bacterium  catenula,  352. 
Balne*otherapie,  452. 
Balneum  vaporis,  118. 
Baths  and  Wash-houses,  40. 

cold,  223,  379. 

immersion  in,  54,  118,  184,  223,  451,  454,  457. 
Bath,  warm  or  tepid — in  smallpox,  118,  119,  120  ;  in  measles,  151  ;  in  scarla- 
tina, 184  ;  in  enteric  fever,   451  ;  Hebra's   apparatus,  121  ;  Barr's  appa- 
ratus, 454  ;   Fardon's  apparatus,  457. 
Battley's  sedative  solution  of  opium,  60. 
Bedsores,  94,  290,  311,  402,  462. 
Belladonna  in  scarlatina,  183. 
Berlin,  regulations  for  disinfection  in,  35. 
Besoin  a  respirer,  275. 
"  Bestuscheff's  tincture,"  222. 
"  Bilious  fever,"  406. 

"Bilious  typhoid"  (Griesinger),  317,  318,  320,  322,  323,  328,  334. 
Bismuth,  salicylate  of,  443. 
Black  Assizes,  247. 

Hole  of  Calcutta,  249. 

vomit,  322,  329. 
"  Black  measles,"  143. 
"Black  smallpox,"  93. 
Bladder  in  fever,  62,  282,  290,  311,  402. 
"  Blasting  typhus,"  262,  293. 
Bleeders,  286. 
Blood-letting,  52. 
/3-naphthol,  443,  444,  449. 
Boils,  94,  171. 
Boulimia,  261,  277,  321. 
Bourbillon,  422. 
Bovine  lymph,  110. 
"  Brain  fever,"  279,  293. 
Branny  desquamation,  27,  140,  163,  375. 
Bristol,  typhus  in,  249. 
Bronchitis — in  smallpox,  100,   123  ;  in  measles,   145  ;  in  erysipelas,  214  ;  in 

typhus,  284,  310  ;  in  enteric  fever,  395. 
Broncho-typhus,  284,  294. 
Bryce's  test  of  vaccination,  111. 
Bubo,  axillary,  in  vaccino-syphilis,  112. 
"  Bubonic  fever,"  243,  291. 
Bubonic  swellings,  171,  291,  403. 


INDEX    OF    SUBJECTS.  41)  1 

Buchlioltz-Wernick  method,  442. 
"  Bukowina  fever,"  317. 
Bullae,  212. 
"Burnt  holes,"  129. 

Caecum  in  enteric  fever,  419. 

Cafe"  noir,  461. 

Caffein,  461,  462. 

"  Calor  mordax,"  162. 

"Calor  praeter  naturam,"  2,  9. 

Calomel  in  enteric  fever,  440,  471. 

Camphor  in  enteric  fever,  448. 

Cancrum  oris,  146,  153,  290,  402. 

Carbolic  acid  hypodermically,  225. 

in  enteric  fever,  443,  444,  445. 

Carboluria,  445. 

Cardiac  failure,  179. 

Carotids,  compression  of  the,  152,  190. 

Carphology,  259,  281. 

Carriers  of  infection,  called  "fomites,"  17,  19,  44. 

Catarrhal  typhus,  241,  284. 

Cathartics,  saline,  52. 

to  be  avoided,  52. 

"Cat's  tongue."  163. 

Cerebral  breathing,  259,  275. 
symptoms,  214. 

Cellulitis,  diffuse,  168,  174,  287. 

"  Change  of  air,"  46. 

Chemical  Carbon  Company's  cones,  45. 

Cheyne-Stokes  breathing,  275. 

Chickenpox,  98,  125,  149  ;  nomenclature,  125  ;  definition,  125  ;  aetiology,  125  ; 
non-inoculable,  126  ;  clinical  history,  127  ;  incubation,  127  ;  invasion, 
127  ;  eruption,  127;  desiccation,  128;  complications  and  sequelae,  129; 
diagnosis,  130;  prognosis  and  treatment,  132. 

China,  103. 

Chloral,  61. 

Chloride  of  sodium  in  fever,  52,  278. 

Chlorine  in  enteric  fever,  443,  446. 

Chorea,  171,  192,  281,  398. 

Chorioiditis  of  relapsing  fever,  327. 

Chromogenic  bacteria,  15. 

Cicatrices — vaccinal,  108  ;  foveate^  111. 


492  INDEX    OF    SUBJECTS. 

Cicatrisation  in  typhoid  ulceration,  422,  425. 
Cicatrix,  or  scar,  of  smallpox,  80. 
Circassia,  103. 
Cirrhosis  of  the  lung,  285. 
City  of  Dublin  Hospital,  120. 
Cladotricb.es,  14. 

Classification  of  continued  fevers,  231. 
disinfectants,  31,  32. 
micro-parasitic  febrile  diseases,  25. 

smallpox,  82  ;  measles,  142  ;  scarlatina,  159  ;  erysipelas,  210. 
Clavele*e,  103,  104. 
Clavelisation,  103. 
Cleft-fungi,  14. 

Clinical  history — of  smallpox,  75  ;  of  chickenpox,  127  ;  of  measles,  136  ;  of  scar- 
latina, 158  ;  of  Eotheln,   195  ;    of  erysipelas,  210  ;   of  febricula,  235  ;  of 
typhus,  255  ;  of  relapsing  fever,  321  ;  of  enteric  fever,  363. 
Cloudy  swelling,  97,  429. 
Coal  tar  derivatives,  459. 
Cocci,  14. 

Coffee  in  fever,  461. 
Coherent  smallpox,  82,  85. 
Cold  affusion,  56,  62,  151,  451. 

bath  treatment — of  fever,  54  ;  of  measles,  151  ;  of  scarlatina,  184,  187  j 
of  erysipelas,  223  ;  of  enteric  fever,  451. 

compresses,  186,  468,  469. 

water  treatment,  53,  186,  450. 
Cohtis,  145,  152. 
Collapse  in  relapsing  fever,  326,  332. 

stage  of  fevers,  26. 
Colon  in  enteric  fever,  419. 
Coma,  280. 

death  by,  416. 
"Coma  vigil,"  of  Chomel,  280  ;  of  Jenner,  280,  296,  382. 
"  Common  infectious  diseases,"  19,  68. 
Communicable  diseases,  12. 

Complications  and  sequelae,  64,  122,  129,  143,  170,  198,  214,  284,  326,  395. 
Compresses — glycerine,  464,  465  ;  cold,  186,  468,  469. 
Condy's  fluid,  433. 

Confluent  smallpox,  77,  82,  84,  89  ;  treatment  of,  114. 
Congestive  hypersemia  of  kidneys,  175. 
Conjunctivitis,  192. 
Constipation  in  enttric  fever,  377,  463,  476. 


INDEX   OF   SUBJECTS.  493 

Constructive  store-albumen,  9. 

Contagion — intimate  nature  of,  12-17  ;  meanings  of  the  word,  12. 

Contagious  diseases,  17,  18,  19. 

Contagiousness  of  erysipelas,  205,  206,  207,  208. 

Contagium,  8  ;  definition  of,  13. 

vivum  of  typhus,  248. 
Continued  fevers,  25,  227,  229,  230. 

Murchison's  classification  of  the,  231. 
Convalescence  stage,  27,  101,  141,  164,  220,  261,  312,  367. 
Convalescent  Homes,  45,  46. 

Convulsions,  63,  144,  152,  190,  281,  282,  290,  311,  398. 
"  Cooling  regimen  "  in  smallpox,  114. 
Cooling  stage  of  fevers,  25. 
Copaiba  rash,  99. 

Copenhagen,  varicella  at,  131  ;  measles  at,  135. 
Cork  Hospital,  106. 
Cork-street  Fever  Hospital,  Dublin,  78,  83,  89,  100,  106,  107,  124,  207,  213, 

230,  256,  257,  265,  282,  288,  290,  297,  298,  300,  306,  313,  361,  385,  387, 

393,  415,  441,  471. 
Corymbose  smallpox,  82,  86. 

Costive  bowels  in  typhus,  312  ;  in  enteric  fever,  377. 
Cowpox,  104. 

Creasote  in  enteric  fever,  448. 
Cri  cerebral,  295. 
Crimean  War,  248,  286,  288. 
Crisis,  8,  26,  236,  260,  264,  272,  322,  394. 
Critical  days,  236,  262. 
Croup— true,  145, 152  ;  false,  152. 
Crusts  of  smallpox,  80, 
"Crystalli,"  126. 
Cubebs  rash,  99. 
Curative  treatment — 30,  48  ;  of  smallpox,  113  ;  of  measles,  150  ;  of  scarlatina, 

183  ;  of  erysipelas,   221  ;   of   typhus,    306 ;    of   relapsing  fever,    330 ;    of 

enteric  fever,  435. 
Cutis  anserinp,  369. 
Cyclical  course  of  fevers,  26. 
Cynanche  tonsillaris,  180. 
Cystitis,  290,  402. 

Daphnia,  or  "water-fleas,"  23. 

Darm-typhus,  341. 

Deafness — in  smallpox,  81  ;  in  typhus,  283  ;  in  enteric  fever,  383. 


494  INDEX   OF   SUBJECTS. 

Death,  sudden,  in  enteric  fever,  403. 

Defervescence,  25,  27,  87,  88,  128,  140,  163,  213,  260,  264,  322,  367,  393. 
Definitions  of  fever,  2,  3,   7,  278  ;  smallpox,  69  ;  chickenpox,  125  ;  measels, 
133  ;  scarlatina,  154  ;  Rotheln,  193  ;  erysipelas,  202,  simple  fever,  233  ; 
typhus,  241  ;  relapsing  fever,  314  ;  enteric  fever,  341. 
Delirium,  60,  83,  123,  143,  169,  214,  259,  279,  322,  381. 

ferox,  83,  259,  279. 

forms  of,  83,  259,  279. 
in  fever,  259. 

low  muttering,  259,  381. 

tremens,  83,  259,  279,  296. 
De  novo  origin  of  typhus,  247  ;  of  enteric  fever,  346,  356. 
Deodorants,  31. 
"  Dermatitis  gangrenosa,"  130. 

Desiccation  stage — of  smallpox;  80  ;  of  varicella,  128. 
Desquamation,  27  ;  varieties  of,  27. 

in  smallpox,  80  ;  measles,  140;  scarlatina,  163  ;  Rotheln,  197  ; 
erysipelas,  218  ;  typhus.  272  ;  enteric  fever,  375. 
Desquamative  nephritis,  146,  170,  174,  176,  189,  290,  303,  401. 
Destitution,  39,  43,  253. 

Diagnosis — of  smallpox,  98  ;  of  varicella,  130  ;  of  measles,  148  ;  of  scarlatina, 
179  ;  of  Rotheln,  198  ;  of  erysipelas,  218  ;  of  febricula,  237  ;  of  typhus, 
294  ;  of  relapsing  fever,  328  ;  of  enteric  fever,  408. 
Diaphoresis,  profuse,  260,  267,  272. 
Diaphoretics,  51,  52,  53. 

Diarrhoea,  64,  81,  100,  123,  145,  152,'277,  289,  327,  333,  377,  399,  464,  477. 
Diary  fever,  234. 
"  Diazo  reaction,"  409. 
Dicrotic  pulse,  273,  376. 
Diet-drinks,  439. 
Diet  in  enteric  fever,  437. 

Dieting  of  convalescence  in  typhus,  312  ;  in  enteric  fever,  477 — 480. 
Dieulafoy,  151. 
Diffuse  cellulitis,  168,  174. 

Digestive  symptoms  in  typhus,  289  ;  in  enteric  fever,  399. 
Digitalis,  459. 

and  opium,  61. 
Diluents,  51. 

Diphtheria,  180,  291  ;  of  pharynx  and  larynx,  145,  168,  170  ;  treatmentof,  188. 
"  Diphtheritic  pock,"  97. 

pyelitis,  177. 
Discrete  smallpox,  77,  82,  89  ;  treatment  of,  114. 


INDEX    OF    SUBJECTS.  495 

Disease,  germ  theory  of,  12,  13. 

Diseases,  communicable  and  non-communicable,  12. 

Disinfectants,  31,  432. 

Disinfection,  31,  47  ;  general  plan  of  Dr.  Emerson  Reynold*1,  32  ;  regulations 

in  Berlin,  35  ;  within  the  body,  37. 
Dissolution  of  the  blood,  91,  169,  286,  378. 
Distinct  smallpox,  77,  82,  89  ;  treatment  of,  114. 
Diuretics,  51,  190. 
Diuretin,  51,  190. 
Dorsal  decubitus,  275,  280. 
Dothie'nente'rie,  342. 

Drainage  system,  necessity  for  efficient,  431. 
Drinking-water  as  a  carrier  of  enteric  fever  poison,  357. 
Dropsy,  177. 
Dublin — smallpox  in,  72,  92  ;    measles  in,  135,  137  ;    scarlet  fever  in,  156  ; 

typhus  and  typhoid  fevers  in,  346-348  ;  enteric  fever  in,  349,  364. 
Dundee  Royal  Infirmary,  261. 
Duodenum  in  enteric  fever,  419. 
Duration  of  typhus,  261  ;  of  enteric  fever,  367. 
Dysentery,  289,  327,  333,  399. 
Dysphagia,  81,  211,  289,  397,  399. 
Dyspnoea.,  81. 

Ear,  diseases  of  the,  95,  145,  152,  171,  191,  283,  383. 
"  Easel-like  "  temperature  range,  163,  172. 
"Eating  Hives,"  129. 
Eaux  aux  jambes,  104. 
Ectogenous  enteric  fever,  35-5,  356. 
Ectrotic  method  of  treatment,  225. 
Eczema.  146,  171,  192. 
rubrum,  2*19. 
Effervescing  draughts,  469. 
Ehrhch's  test,  409,  411. 
Eiterungsfieber,  88. 
Elimination,  promotion  of,  48. 
Emaciation — in  typhus,  300  ;  in  enteric  fever,  383. 
Embolism,  287. 
Emetics  in  enteric  fever,  469. 
Emphysema,  general,  397. 

Emunctories,  the  Great,  51.  "■  I 

Enanthem,  147.  -       .       , 


4%  INDEX   OF   SUBJECTS. 

Endemic  disease,  1 9  ;  definition  of,  20. 

fever,  231,  346. 
Endocarditis,  287,  398;  ulcerative  (septic),  413. 
Enemata  in  enteric  fever  468. 

ice-water,  470. 
EDgland,  deaths  from  relapsing  fever  in,  315. 

deaths  from  small-pox  in,  105. 

smallpox  inoculation  illegal  in,  103. 
Engouement,  422,  426. 
Enterica  sine  enteritide,  421, 

Enteric  fever,  230,  231,  292,  328,  335  ;  nomenclature,  339  ;  synonyms.  341  ; 
definition,  341  ;  literature  and  history  of,  342;  geographical  distribution, 
344 ;  aetiology,  345 ;  predisposing  causes,  349 ;  recurrence  of,  351  ; 
exciting  cause,  351  ;  bacteriology,  351  ;  autochthonous,  autogenous, 
or  entogenous,  and  ectogenons,  355  ;  paths  of  infection,  357  ;  mode  of 
invasion,  360;  clinical  description  of,  363;  incubation,  363;  invasion, 
364 ;  glandular  enlargement,  364  ;  ulceration  and  sloughing,  366  ;  amphi- 
bolic stage,  366  ;  lysis,  367  ;  convalescence,  367  ;  duration,  367  ;  analysis 
of  symptoms,  369  ;  physiognomy,  369  ;  surface  in,  369  ;  rose-spots,  369  ; 
circulation,  375  ;  dicrotism  in,  375  ;  respiratory  symptoms,  376  ;  digestive 
symptoms,  376  ;  constipation,  376  ;  diarrhoea,  377  ;  intestinal  haemorrhage, 
377  ;  urinary  system,  3S0  ;  nervous  system,  381  ;  organs  of  special  sense 
in,  382 ;  emaciation  in,  383  ;  relapse,  384 ;  temperature,  392,  408  ;  com- 
plications and  sequelae,  395  ;  sudden  death  in,  403  ;  co-existence  of  other 
specific  diseases  with,  404  ;  varieties,  405  ;  diagnosis,  408  ;  prognosis  and 
mortality,  414  ;  pathological  anatomy,  416  ;  modes  of  death,  416  ;  intestinal 
and  splenic  lesions,  419  ;  prophylaxis,  430  ;  disinfection  of  excreta,  433  ; 
curative  treatment  or  management,  435  ;  antipyretic  treatment,  450  ; 
laparotomy  in,  472  ;  management  in  convalescence,  475. 

Entogenous  enteric  fever,  355,  356. 

"  Ephemera,"  233,  235. 

Ephemeral  fever,  147,  233,  234. 

"Epidemic  Constitution  "  (Sydenham),  143,  149,  156,  284. 

Epidemic — disease,  19  ;  definition  of,  20  ;  fevers,  231. 
Hospitals,  45. 

Epidemic  rose  rash,  142,  148,  193  (see  "  Eotheln  "). 

Epistaxis,  145,  152,  283,  326,  333,  383,  398,  462. 

Ergot,  123,  124,470. 

Eruption,  24  ;  stage  of,  27  ;   in  smallpox,  78  ;  varicella,  127  ;  measles,   139  ; 

scarlatina,  162  ;  Rbtheln,  196  ;  erysipelas,  211  ;  typhus,  258 ;  enteric  fever, 

370. 
Eruptions,  septicemic,  375. 
Eruptive  fevers,  25,  65,  67,  229.  .      ; 


INDEX    OF    SUBJECTS.  497 

Erysipelas,  99,  180,  202,  291,  292,  402  ;  nomenclature,  202  ;  etymology  of  the 
word,  202  ;  definition,  202  ;  aetiology,  203  ;  idiopathic  or  medical,  203  ;  trau- 
matic or  surgical,  203  ;  predisposing  causes,  204  ;  traumatism,  204  ;  "  poso- 
comiale,"  204  ;  contagiousness  of,  205  ;  throat  affection  in,  208  ;  inoculable, 
209  ;  bacteriology  of,  203,  209  ;  clinical  history,  210  ;  incubation.  210  ; 
invasion,  211  ;  eruption,  211  ;  faucium,  211  ;  defervescence,  213  ;  migrans, 
213,  219;  pulmonum,  213;  temperature  in,  213;  complications  and 
sequelae,  214  ;  pathology,  215  ;  diagnosis,  218  ;  prognosis,  219  ;  treatment, 
220  ;  of  the  pharynx,  289. 

"  Erysipele  salutaire,"  209  ;  ambulant,  213  ;  des  nouveau-nes,  214. 

Erythema,  179,  219,  372  ;  papular,  373. 

Erythematous  accidental  rashes,  76,  77,  90,  371. 

Essential  fever,  2,  16,  18. 

phenomena  of  fever,  9. 
diseases,  16. 

Essera  Vogelii,  193. 

Etat  pointing  422,  427. 

Etymology  of  the  word  "erysipelas,"  202. 

Eucalyptus  oil  in  enteric  fever,  448. 

Eustachian  tubes  in  smallpox,  8 1 . 

Exanthema,  meaning  of  term,  68. 

Exanthemata,  25,  65,  67,  68. 

Cullen's  definition  of  the,  67. 

Exciting  causes  of  disease,  38,  70,  126,  134,  157,  193,  205,  243,  318,  351. 

Excreta  in  enteric  fever,  disinfection  of,  433. 

Expectant  treatment,  184,  221. 

Eyes  and  eyelids  in  smallpox,  94,  122. 

in  typhus,  282  ;  in  relapsing  fever,  326  ;   in  enteric  fever,  382. 


Facultative  parasites,  14. 

Eacies  typhosa,  271,  369. 

Fadenpilze,  13. 

Fairchild's  zymine  peptonising  powders,  438. 

"  Fall  fever,"  340,  349. 

Famine  and  pestilence,  39. 

fever,  39,  313  (see  "  Relapsing  Fever  ")■ 
False  croxip,  144. 

Faroe  Islands,  measles  in,  135,  137. 
Fastigium  or  acme,  25,  76,  263,  393. 
Fatigue,  39,  41. 
Fatty  degeneration,  97. 
Fatuity — after  typhus,  288  ;  after  enteric  fever,  398. 

2   K 


498  INDEX   OF    SUBJECTS. 

Febricula,  231,  233,  328  ;  nomenclature,  233  ;  definition,  233  ;  aetiology  and 
history,  234  ;  auto-infective,  235  ;  clinical  history,  235  ;  modes  of  crisis  in, 
236  ;  diagnosis,  237 ;  prognosis,  237  ;  pathology,  237  ;  treatment,  237. 

Febrile  urticaria,  373. 

Febris  complicata,  6. 
mixta,  6. 
simplex  pura,  6. 
variolosa  sine  exanthemate,  92. 

Feeding  the  fever  patient,  57. 

Ferment,  13. 

Fermentation,  13. 

Fermentative  bacteria,  15. 

Ferret-eye  of  typhus,  259,  282. 

Fever,  intimate  nature  of,  1-11  ;  meaning  of  the  term,  1,  278  ;  symptomatic 
or  idiopathic,  2  ;  primary,  specific,  or  essential,  2,  16  ;  secondary,  non- 
specific, or  accidental,  2  ;  cardinal  fact  in,  2  ;  "  calor  praeter  naturam," 
2,  9  ;  definitions  of,  2,  3,  7  ;  a  "  dissolution,"  6  ;  pathology  of,  8  ;  essen- 
tial phenomena  of,  9  ;  uses  of  water  in,  10  ;  malarial  or  paludaL  19 ; 
classification  of,  25,  229  ;  preventive  treatment  of,  40  ;  curative  treat- 
ment of,  48  ;  of  suppuration,  88  ;  non-specific,  231  ;  specific,  231. 

Fever  nurse,  qualifications  for  a,  307. 

"Feverish  cold,"  253. 

Feverishness,  2. 

Fieberabnahme,  27. 

Fievre  muqueuse,  406. 
typho'ide,  340. 

Fiji,  measles  in,  135. 

Fish  as  a  fever  diet,  479. 

Fission  fungi,  13,  14. 

Flaky  desquamation,  27,  140, 163. 

Floccitatio,  259,  281. 

Foetal  heart  in  typhus,  274. 

Foetus  in  utero,  heart  of  the,  274. 

Fomites,  17,  19,  44,  245,  254. 

Food,  scarcity  of,  39,  43. 

suitable  in  fever,  57,  478. 

Furfuraceous  desquamation,  27,  140,  163. 

Furuneular  diathesis,  94,  100. 

Gangrene,  hospital,  290,  291. 
Gangrene  of  the  lung,  286. 

skin,  215,  290,  311,  402,  462. 

vulva,  146,  153. 


INDEX    OF    SUBJECTS.  49'J 

Gangrenous  stomatitis,  146,  153,  290. 
Gargouillement,  277,  341,  365,  376,  411. 
Gastric  fever,  406,  407. 
'•Gastro -entente,"  342,  406,  419. 

Geographical  distribution  of  smallpox,  70  ;  of  measles,  133  ;  of  scarlatina,  155  ; 
of  erysipelas,  205  ;  of  typhus,  242  ;  of  relapsing  fever,  317  ;  of  enteric,  344. 
Georgia,  103. 

Germ  theory  of  disease,  12,  13. 
German  treatment  of  smallpox,  117. 
Germicides,  31. 
Glanders,  99. 
Glandular  enlargement  stage  in  enteric  fever,  364. 

enlargements,  145,  153. 
Glasgow  Royal  Infirmary,  245, 
Globular  bacteria  of  erysipelas,  216. 
Glomerulo-tubal  nephritis,  175. 
Glossitis  variolosa,  84,  95. 

Glottis,  oedema  of  tue,  95,  100,  123,  181,  226,  289,  497. 
Glycerine  poultice,  464,  465. 
"Golden  rule,"  Jenner's,  109. 
Grafenberg  **  wet-pack,"  54. 
Gram's  method  of  staining,  354. 
Granular  degeneration,  97. 
"  Grease,"  104. 
Greece,  103. 
"Grippe,  la,"  20. 
"  Grisolle  sign,"  98,  148. 

Guaiacum  and  oxonic  ether  test  for  haemoglobin,  185 
Guy,  Danse  de  St.,  171. 
Guy's  Hospital,  161,  415. 

Haematemesis,  289. 
Hematuria,  290,  401, 
Haemoglobin,  test  for,  185. 
Hemoglobinuria,  paroxysmal,  185. 
Haemophilia,  acute,  91,  92,  170,  286,  290,  398. 
Haemoptysis,  286. 

Haemorrhage,  intestinal,  64,  289.  326,  378,  394,  452,  469. 
in  enteric  fever,  378,  394. 

in  relapsing  fever,  326. 
Hemorrhagic — putrid  fever,  398  ;  smallpox,  90-92,  98,  100  ;  treatment  of,  123. 

diathesis,  91,  92. 


500  INDEX    OF   SUBJECTS. 

"Halo"  of  smallpox  pustule,  79  ;  of  vaccina,  109,  111. 

Hair,  fall  of  the,  85,  173,  218,  272,  373. 

Hampstead  Hospital,  106. 

Hardwicke  Fever  Hospital,  Dublin,  86,  106. 

"  Hatching  "  stage  of  fevers,  26. 

Hazeline,  462. 

Headache,  59  ;  in  typhus,  256,  257,  278  ;  in  enteric  fever,  381. 

Heart,  effect  of  sipping  upon  the,  476. 

in  smallpox,  98  ;  in  scarlet  fever,  178  ;   in  typhus,  273  ;  in  relapsing 

fever,  324  ;  in  enteric  fever,  418. 
of  the  fetus  in  utero,  274. 
Heat,  adjusting  mechanism,  5. 
animal,  theory  of,  4. 
discharging  mechanism,  5. 
producing  mechanism,  5. 
Hectic  state,  26. 
Hefenpilze,  13. 
"  Heil-fieber,"  7. 
Hemiplegia,  288. 
Hendon  cow  disease,  157,  158. 
Hereditary  predisposition  to  disease,  38. 
Herpes,  130,  271. 

vaccinal,  112,  146. 
zoster,  219. 
Herpetic  fever,  233,  236. 
Hiccough,  63,  259,  382. 
Hoarseness,  81. 

Homerton  Fever  Hospital,  106,  345. 
Hornpox,  89. 

"Hospital  gangrene,"  290,  291. 
Hospitals,  epidemic,  45. 
"  Hot  regimen  "  in  smallpox,  113. 
House  drain,  description  of,  431. 
Humanised  lymph,  110. 
Hungerpest,  39,  313. 
"  Hybrid  measles,"  195. 

scarlatina,"  195. 
Hydronaphthol  in  enteric  fever,  443,  444. 
Hygienic  manangement  of  enteric  fever,  436. 
Hyperemia,  simple,  371. 
Hyperesthesia,  63,  283,  383,  398. 


INDEX    OF   SUBJECTS.  501 

Hyperpyrexia  or  "excessive  fever,"  5,  7,  53,  88,  169,  181,   186,  214,  264,  265, 

268-270,  325,  416. 
Hyphomycetes,  13. 
Hypnotics,  60. 
Hypostatic  congestion  of  the  lung,  275,  285. 

Ice,  122,  186,  188. 
Ice-cradle,  55. 

poultice,  64,  468,  469. 
water  enemata,  470. 
Iceland,  enteric  fever  in,  344. 
Icterus,  289,  328,  330,  399. 
Idiopathic  erysipelas,  203. 

fever,  2. 
Idiosyncrasy,  252,  350. 
Ileo-csecal  valve,  419. 
Ileo-typhus,  341. 
Ileum  in  enteric  fever,  420. 
Immersion  iu  cold  baths,  54,  454. 
Immunity,  theories  of,  21,  434,  482. 

acquired,  22. 

natural,  22. 

after  enteric  fever,  350. 
Impffeder,  110. 
Incontinence  of  urine,  311. 

Incubation,  period  of,  13,  26,  75,  127,  136,  159,  160,  195,  210,  255,  363. 
India,  relapsing  fever  in,  317. 
Infantile  remittent  fever,  340,  407. 
Infection — carriers  of,  17,  19,  44,  245,  254;  paths  of,  in  enteric  fever,  357  ;  and 

immunity,  482. 
Infections-fieber,  6,  18,  68. 
Infections-krankheit,  13,  18. 
Infectious  diseases,  17,  18. 

microbes,  15. 

myocarditis,  178. 
Infective  diseases,  13,  18. 

fever  (Infections-fieber),  6,  18,  67,  68. 
granuloma,  422. 
Inflammation  of  serous  membranes,  178. 

synovial  membranes,  178. 
Inflammatory  fever,  235. 
Influenza,  20,  412. 


502  INDEX   OF   SUBJECTS. 

Inhalation  of  oxygen,  462. 
Initial  fever  of  smallpox,  87. 

stage  of  fevers,  26. 
Inoculation,  17,  43,  102,  202,  205. 

for  smallpox,  illegal,  103  ;  for  measles,  137  ;  for  scarlet  fever,  157  ; 
for  erysipelas,  209. 
Intemperance,  alcoholic,  39,  42,  252. 
Intermittent  fevers,  19,  25,  229. 
Internal  administration  of  water  in  fever,  11. 
Interstitial  nephritis,  176,  296. 
Intestinal  haemorrhage,  64,  289,  378,  394,  452,  469. 

lesions  of  enteric  fever  inconstant,  420. 
Intimate  nature  of  contagion,  12-17. 

fever,  1-11. 
Intolerance  of  sound,  283. 
Inunction  in  scarlatina,  185. 
Invasion,  period  of,  25,  26,  28,  29,  76,  127,  138,  144,  161,  196,  211,  257,  360, 

364. 
Ireland,  Public  Health  Act,  1878,  38,  41,  46,  47. 
smallpox  inoculation  illegal  in,  103. 
typhus  in,  243  ;  relapsing  fever  in,  313,  314,  315. 
"  Irish  ague,"  241. 
Iritis,  94,  333. 
Iron — in  smallpox,  115  ;  in  scarlatina,  192  ;  in  erysipelas,  222  ;  in  enteric  fever, 

481. 
Isolation,  27,29,44,  45,  47,  102,  183. 
Itching  in  Kotheln,  197. 

Jaeger  system  of  clothing,  191. 

Jaundice — in  typhus,  289  ;  in  relapsing  fever,  328,  330  ;  in  enteric  fever,  399. 

Jejunum  in  enteric  fever,  419. 

Joint  disease  in  smallpox,  96. 

Jungle  fever,  19,  294,  295. 

Kairin,  459. 

Katabolism,  4. 

Keratitis,  94,  122,  146,  171,  192. 

Kidneys — lime  deposits  in,  176  ;  in  smallpox,  97  ;  in  scarlatina,  170,  174  ;  in 

enteric  fever,  418. 
Knee-jerk,  289. 
KcD/Uo  aypvTTv6v,  381. 
"  Kuhpockenimpfung,"  104. 


INDEX    OF   SUBJECTS.  503 

Lactation  in  enteric  fever,  402. 
Lamellar  desquamation,  27. 
"  Landfarsot  "  of  Iceland,  344. 
Laparotomy  in  enteric  fever,  472,  473,  474. 

Laryngitis— in  small-pox,  95,  122  ;  in  measles,  144,  145  ;  in  erysipelas,  226  ; 
in  typhus,  286  ;  in  enteric  fever,  396,  418. 
membranous,  145,  226,  286,  396. 
Laryngo-typhus,  286. 
Larynx  in  enteric  fever,  418. 
Latent  enteric  fever,  406. 

period,  26,  28,  364. 

scarlatina,  167. 
Laxatives,  52. 
"  Leaguer  sicknesses,"  241. 
"  Leaven,"  13. 

Leeching,  52,  192  ;  contraindicated  in  erysipelas,  224. 
Leipzig,  Rbtheln  at,  194. 
Leiter's  tubes,  452. 
Leptotriches,  14. 
"Lethargus,"  382. 
Leucin,  278. 

Leucocytes  as  phagocytes,  23. 
Leucocytosis,  215. 
Levuka,  measles  at,  135. 
Lichen,  130  ;  vaccinal,  112. 
Liebig's  beef  tea,  439. 

Lime  deposits  in  kidneys  in  scarlatina,  176. 
Literature — of  typhus,  242  ;  of  enteric  fever,  342. 
Liver — in  smallpox,  97  ;  in  typhus,  277  ;  in  enteric  fever,  418  ;  effect  of  sipping 

upon  the,  476. 
*'  Londonderry,"  steamship,  249. 

London  Fever  Hospital,  159,  230,  231,  245,  251,  263,  287,  297-299,  316,  321, 
329,  349,  370,  388,  389,  415,  451. 
Hospital,  55,  188. 

Smallpox  Hospital,  86,  106,  108,  117,  292. 
smallpox  in,  71,  72. 
Lufthunger,  275. 
Lungs,  cirrhosis  of  the,  285. 

enteric  fever  entering  by  the,  360. 

gangrene  of  the,  286. 

hypostatic  congestion  of  the,  275,  285. 

tuberculosis  of  the,  286. 


504  INDEX   OF   SUBJECTS. 

Lymph,  103,  110. 
Lymphangeiitis,  219. 

capillary,  in  erysipelas,  216. 
Lymphatic  glands — in  Kbtheln,  193,  197  ;  in  erysipelas,  218. 
Lysis,  8,  26,  367,  394. 


Macrophages,  217. 

Macuhe,  241,  258,  271,  370,  371. 
cserulese,  236,  370,  371. 

Magdeburg  Hospital,  257,  294. 

Magnesium,  salicylate  of,  444. 

"  Maitre  bouton,"  104. 

Malaise,  75. 

Malaria,  19. 

Malarial  fevers,  19. 

Malignant  smallpox,  90,  91,  100. 
stage  of  typhus,  259. 

Mania,  288,  398. 

Marasmus,  403. 

Marylebone,  scarlatina  in,  157,  158. 

Mater  Misericord  ise  Hospital,  404. 

Maturation  in  smallpox,  79. 

fever  of  smallpox,  88. 

"Master  Pock,"  104. 

Meat  as  a  carrier  of  enteric  fever  poison,  359. 

Meath  Hospital,  56,  58,  83,  89,  115,  137,  160,  207,  246,  262,  265,269,  273,  282, 
288,  324,  361,  383,  407,  426,  458. 

Measles,  98,  133,  180,  295 ;  nomenclature,  133  ;  definition,  aetiology,  and 
bacteriology,  133,  134- ;  stages  of  infectiveness,  134  ;  "striking  distance," 
134  ;  epidemics  in  Faroe  and  Fiji,  135  ;  seasonal  prevalence,  135  ;  clinical 
history,  136  ;  incubation,  136  ;  invasion,  138;  eruption,  139;  tempera- 
ture, 138,  140,  146  ;  desquamation,  140  ;  convalescence,  141  ;  relapse  in, 
141  ;  classification,  142;  complications,  143  ;  convulsions,  144  ;  laryngitis, 

144  ;  suffocative  catarrh,  144,  145  ;  epistaxis,  145  ;  diarrhoea,  145  ;  croup, 

145  ;  otitis,  145  ;  pathology,  147  ;  diagnosis,  148  ;  prognosis,  149  ;  treat- 
ment, 150  ;  "  fiery,"  154. 

Measly  rash  of  typhus,  258,  370. 

"  Medical  erysipelas,"  203. 

Medicinal  rashes,  99,  371. 

"  Meisterpocken,"  104. 

Mekena,  398. 

Melbourne,  enteric  fever  in,  358. 


INDEX    OF   SUBJECTS.  505 


Membranous  croup,  145. 

desquamation,  27. 
Meningitis,  288,  295,  398. 

Menorrhagia  — in  smallpox,  91,  124  ;  in  enteric  fever,  402. 
Mental  disease  in  typhus,  288. 
Mercury,  biniodide,  in  scarlatina,  183. 
Metabolic  theory  of  fever,  6. 
Metabolism,  4,  7. 
Meteorism,  63,  280,  376,  467. 
Mesenteric  lymph  glands  in  enteric  fever,  428. 
Miasm,  19. 

Miasmatic-contagious  diseases,  18  ;  definition  of,  19. 
Miasmatic  diseases,  18  ;  definition  of,  18. 
Microbes,  9,  14. 

pathogenic  and  non-pathogenic,  1 4. 

infectious  and  non-infectious  but  toxic,  15. 

aerobic  and  anaerobic,  15. 
Micrococci  erysipelatosi,  209. 
Micro-organisms  classification  of,  13. 

in  fever,  8,  9  (See  "  Microbes"); 
Micro-parasitic  diseases,  12,  18,  25,  68. 
Microphages,  217. 
Microspheres  of  Cohn,  216. 
"Micro-strife,"  23,"217. 
Middlesex  Hospital,  222,  345,  404,  451,  457. 
Milch  cows,  disease  in,  157. 
Miliary  eruptions,  371. 

Milk  as  a  carrier  of  enteric  fever  poison,  358. 
Milk  as  a  fever  food,  437. 
Mineral  acids,  49. ' 
Mistura  cretse,  465. 
Mistura  spiritus  vini  gallici,  439. 
"  Mixture  anglaise,"  465. 
Modified  smallpox,  69,  89,  90,  93. 
Montrose,  erysipelas  at,  208. 
"  Morbific  Agent,"  18. 
Morbilli,  133.     (-See  Measles.) 
Morbilliform  rash  of  typhus,  258. 
Morbilli  ignei,  154. 
nigri,  143. 

sine  morbillis,  140,  142. 
catarrho,  140,  142. 


506  INDEX   OF   SUBJECTS. 

Morbillous  catarrh,  145. 

Mortality — in  confluent  smallpox,  84  ;  chickenpox,  132  ;  measles,  149  ;  scar- 
latina, 181  ;  RStheln,  201  ;  erysipelas,  220  ;  typhus,  297  ;  relapsing  fever, 
329  ;  enteric  fever,  414. 

Mottling,  subcuticular,  269. 

Moulds,  13. 

Mucorini,  13. 

Mucous  membranes — in  smallpox,  80,  84  ;  in  measles,  138. 

Mulberry  rash  of  typhus,  259,  370. 

Munich,  enteric  fever  in,  350. 

Muscular  lesions  in  typhus,  280,  288. 

Mycoprotein,  14. 

Myocarditis,  acute  parenchymatous,  178,  287,  418,  429. 

Myositis  typhosa,  429. 

Nails,  atrophic  furrow  across,  272,  375. 

shedding  of  the,  173. 
Naphthalin  in  enteric  fever,  448,  455. 
Natural  immunity,  22. 
smallpox,  93. 
Nausea,  321,  376. 
Necker  Hospital,  Paris,  130,  149. 
Necrosis,  403. 

Negroes,  risk  from  smallpox  to,  72. 
Nephritis,  acute  desquamative,  146,  170,  174-176,  189,  290,  303,  401. 

interstitial,  176,  296. 
Nervous  excitement,  60,  258. 

prostration,  259. 

respiration,  376. 

symptoms  of  fever,  8,  288,  398. 

system,  thermal,  5. 

typhus,  293. 
Netherfield.  Fever  Hospital,  Liverpool,  427,  429. 
Nettle-rash,  219,  371. 
Neuralgia  in  enteric  fever,  381. 
Neuralgic  pains,  63,  381,  398. 
Neuritis,  peripheral,  288. 
Neurotic  theory  of  fever,  6. 
Neutralisation  of  fever  poison,  48,  49. 
New  York,  Rotheln  in,  195,  196. 
Nitre  in  relapsing  fever,  331. 
Noma,  146,  153,  290,  402. 


tNDEX    OF   SUBJECTS.  507 

Nomenclature— of  smallpox,  69  ;  varicella,  125  ;  measles,  133  ;  scarlatina,  154; 

Rotheln,   193  ;  erysipelas,  202  ;   febricula,  233  ;  tvphus,  239  ;  relapsing 

fever,  313  ;  enteric  fever,  339. 
Non-cnmmunicable  diseases,  12. 
Non-infectious  microbes,  15. 
Non-pathogenic  microbes,  14. 
Non-specific  fever,  2,  231. 
North  Dublin  Union  Workhouse,  297. 
Northern  Hospital,  Liverpool,  454. 

Nose — in  typhus,  283  ;  in  relapsing  fever,  324,  326  ;  in  enteric  fever,  383. 
Nose-bleeding,  145,  152,  283,  326,  333,  383,  398,  462. 
Nurse,  fever,  qualifications  for  a,  307. 
Nursing  in  typhus,  307. 

Nutrition  of  body  to  be  maintained  in  fever,  48,  57. 
Nux  vomica  in  tympanites,  467. 
Nystagmus,  281. 

O'Beirne's  long  tube  for  tympanites,  468. 

Obligate  parasites,  14. 

"  Ochlotic  fever,"  241. 

Odour  in  smallpox,  80  ;  measles,  139  ;  typhus,  272v 

CEdema,  290,  312. 

of  the  glottis,  95,  100,  123,  181,  226,  289,  397. 
Onset  of  fevers,  25. 
Ophthalmia,  94,  146,  153,  326,  333. 
Opium,  60,  266,  471  ;  contra-indications  for,  61. 
Oriental  plague,  243,  291. 
Otitis — in  smallpox,  95  ;  in  measles,  145,  152  ;  in  scarlatina,  171,  191  ;  in  typhus, 

283  ;  in  enteric  fever,  399. 
Otorrhoea,  399. 

Overcrowding,  39,  241,  243,  252,  253. 
Oxygen,  inhalation  of,  462. 
Ozonic  ether  and  guaiacum  test  for  haemoglobin,  185. 

Pains,  rheumatoid  and  neuralgic,  63. 

Paludal  fevers,  19. 

Pandemic  disease,  19  ;  definition  of,  21. 

Panophthalmitis,   94,  171. 

Papular  erythema,  373. 

Paracentesis  in  perforation,  472. 

Paraplegia,  288. 

Parasites,  14  ;  obligate  and  facultative,  14. 

Parasitic-contagious  diseases,  18  ;  definition  of,  19. 


508  INDEX    OF   SUBJECTS. 

Paralyses  in  typhus,  280,  288  ;  in  enteric  fever,  398. 
Parenchymatous  myocarditis,  178,  287. 

nephritis,  146,  170,  174-176, 189,  281,  290,  303,  401. 
Paresis  after  typhus,  311. 
Parotitis,  403. 
"  Parrot-tongue,"  277. 
Patellar  reflex,  289. 
Pathogenic  microbes,  14,  15. 
Pathology  of  the  infective  or  specific  fevers,  8. 

smallpox,  96  ;  measles,  147  ;  scarlatina,  173  ;  Rotheln,  198  ;  ery- 
sipelas, 215  ;  febricula,  237  ;  typhus,  300  jrelapsing  fever,  329  ; 
enteric  fever,  416. 
Peeling  stage  of  fevers,  27. 
Pemphigus,  130,  219. 

gangraenosus,  129. 
Peptonised  food,  57,  184. 

Perforation  of  the  intestine,  394,  400,  427,  472. 
Pericarditis,  287,  398. 
Perichondritis  laryngea,  95,  100,  286,  397. 

typhosa,  286,  397. 
Periodicity  of  smallpox,  71. 
Periostitis,  403. 
Peripheral  neuritis,  288. 
Peritoneum,  rupture  of  the,  427. 
Peritonitis,  178,  215,  399,  400,  471. 

in  relapsing  fever,  327  ;  in  enteric  fever,  376,  383,  399,  4C0,  471. 
Persia,  103. 

Petechise,  77,  242,  260,  271. 
"Petechia  sine  febre,"  295. 

Peyer's  patches,  341,  360,  362,  378,  414,  420,  422-424,  426,  427,  475. 
Phagocytes,  23,  434. 
Phagocytosis,  7,  22,  434,  486. 
Pharyngitis,  122,  145,  399. 

Pharynx,  diphtheria  of,  145  ;  erysipelas  of  the,  289. 
Phenazone,  459. 
Phosphorus,  62. 
Photophobia,  49,  60,  283. 
Phimosis,  96. 
Phlebitis,  septic,  145,  287. 
Phlegmasia  alba  dolens,  287,  312,  396. 
Phlegmonous  inflammation,  diffuse,  219. 
Phylaxins,  434. 
Picote,  69,  105. 


INDEX   OF   SUBJECTS.  50'.) 

Pigment-forming  bacteria,  15. 

Pilocarpin  for  uraemia,  190. 

"  Pin-hole  pupil "  of  Graves,  259,  282. 

Pitting  in  smallpox,  prevention  of,  116-118. 

Plague,  oriental,  243,  291. 

Plaques  dures,  423. 

gaufrees,  423. 

molles,  423. 

re'ticule'es,  423,  427. 
Plasmodium  malariae,  19. 

Pleuritis,  95,  146,  171,  178,  214,  286,  395  ;  treatment  for,  191. 
Plumbism,  296. 
Pneumo-thorax,  397. 
Pneumotoxins,  484. 
Pneumo-typhus,  284,  294. 
Pneumonia,  95,  145,  213,  214,  237,  264,  285,  296,  326,  357,  360,  361,  395,  482. 

migrans,  213  ;  pythogenic,  285,  357,  360,  361. 
Pneumonic  fever,  264,  285,  360,  482. 
Pock,  diphtheritic,  97. 

"  Pocks  "  of  smallpox,  69,  78  ;  their  life-history,  79. 
Potus  imperialis,  51. 

Predisposing  causes  of  disease,  38,  47,  71,  72,  135,  156,  204,  250,  251,  316,  349. 
Predisposition  to  disease,  38. 
Pregnancy  in  typhus,  299  ;  in  enteric  fever,  402. 
Preventable  diseases,  30. 
"  Preventive  Medicine,"  30,  49. 

Preventive  treatment,  30,  40,  47  ;  of  smallpox,  102  ;  of  measles,  150  ;  of  scar- 
latina, 182  ;  of  typhus,  305  ;  of  relapsing  fever,  330  ;  of  enteric  fever,  430. 
Primary  fever,  2. 
Principles  of  treatment,  48. 

Prodromal  fever — of  smallpox,  76,  87  ;  of  cfcickenpox,  127;  of  measles,  138  ; 
of  scarlatina,  161  ;  or  erysipelas,  211  ;  of  typhus,  258  ;  of  enteric 
fever,  364. 
stage  of  fevers,  26. 
Prognosis — of  smallpox,  99  ;  of  chickenpox,  132  ;  of  measles,  149  ;  of  scarla- 
tina, 181  ;    of  Rbtheln,  201  ;    of  erysipelas,  219  ;    of  febricula,  237  ;    of 
typhus,  296  ;  of  relapsing  fever,  329  ;  of  enteric  fever,  414. 
Prophylaxis,  30,  40,  47  ;  of  smallpox,  102  ;  of  measles,  150  ;  of  scarlatina,  182  ; 

of  typhus,  305  ;  of  relapsing  fever,  330  ;  of  enteric  fever,  43  K 
Proteids,  defensive,  434,  484,  4£€. 
Protomyces,  318.  ;l   ; 

Protoplasm,  9,  14. 
Pseudo-crisis  in  typhus,  263.  .  -  -  -'• 


510  INDEX    OF    SUBJECTS. 

Psorenterie,  174. 

Ptomains,  15,  16,  22,  479. 

Ptyalism  in  smallpox,  83. 

Public  baths  and  wash-houses,  40. 

Public  Health  (England)  Act,  1875,  41. 

(Ireland)  Act,  1878,  38,  41,  46,  47. 
(Scotland)  Act,  41. 
Puerperal  fever,  411,  412. 

state,  214. 
Pulmonary  tubercle,  396. 
Pulse,  dicrotic,  375,  376. 

in  scarlatina,  161  ;  typhus,  273  ;  enteric  fever,  375,  376. 
Punctiform  bacteria  of  Ehrenberg,  216. 

Pupils,  "  pin-hole,"  259,  282;  inequality  of,  283  ;  dilated,  382. 
Purpura  and  enteric  fever,  371. 
typhus,  272,  295. 
variolosa,  92. 
Purpuric  rashes,  77. 

smallpox,  90,  91,  92 ;  measles,  142.  143. 
Putrefactive  bacteria,  15. 
Putrid  stage  of  typhus,  259. 
Putrilage,  422,  429. 

Pyaemia,  96,  100,  171,  181,  191,  215,  286,  398,  411,  412. 
Pyelitis,  diphtheritic,  177. 
Pyretologia,  83. 

Pyrexia — meaning  of  the  term,  2  ;  may  be  of  use  in  the  organism,  7. 
Pyrogenetic  stage,  25,  26,  393. 
Pythogenic  fever,  339,  341,  356. 

pneumonia,  285,  357,  360,  361. 

Quarantine,  27,  29,  43,  47. 

Quinine  the  best  antipyretic,  50,  458  ;  antiseptic  use  of,  115  ;  in  scarlatina,  186  ; 

in  erysipelas,  222  ;  in  enteric  fever,  443,  447,  458. 
Quinsy,  180. 

Rashes,  accidental — in  smallpox,  76,  90,  99  ;  in  enteric  fever,  371. 

medicinal,  99. 

of  enteric  fever,  365,  369. 
Rattlesnake,  bite  of  the,  274. 
"  Ravaglione,"  126. 

Receptivity,  28,  30,  43,  102  ;  lessening,  means  for,  38. 
Recrudescences,  220,  367,  384. 
Recurrent  measles,  141  ;  enteric  fever,  351. 


INDEX   OF   SUBJECTS.  511 

"Red  gum,"  130. 

Reduction  of  temperature,  48,  52  ;  in  enteric  fever,  450. 

Refuges,  in  quarantine,  44. 

Regimen,  cooling,  in  smallpox,  114. 

hot,  in  smallpox,  113. 
Relapse  in  measles,  141  ;  in  scarlatina,  164  ;  in  erysipelas,  220  ;  in  typhus,  263  ; 

in  enteric  fever,  384,  429. 
Relapsing  fever,  231,  232,  237,  313,  390,  411  ;  nomenclature,  313  ;  definition, 
314  ;  aetiology,  314  ;  deaths  in  England,  Ireland  and  Scotland  from,  315  ; 
predisposing  causes,  316  ;  geographical  distribution,  317  ;  exciting  cause, 
318  ;    bacteriology   of,    318  ;    no  immunity  conferred   by,    3   0  ;    clinical 
description,  321  ;  stages  and  duration,  325  ;  temperature  in,  325  ;  com- 
plications and  sequelae  of,  326  ;  diagnosis,  328  ;  prognosis  and  mortality, 
329  ;  pathological  anatomy,  329  ;  treatment,  330. 
Remittent  fever,  19,  26,  295,  411 ;  infantile,  407. 
Renal  disease,  181. 
Repair,  4. 
Resorcin,  460. 

Respiration,  cerebral,  259,  275. 
Chesne-Stokes,  275. 
in  typhus,  274,  275. 
nervous,  275. 
Rest,  absolute,  471. 

"  Resting  spores,"  16,  232,  249,  319,  354,  356. 
Retention  of  urine,  282. 
Retinal  haemorrhages,  94. 
Retinitis  albuminurica,  171. 
Retrograde  metamorphosis,  4. 
Re- vaccination,  periodical,  108. 
Rheumatic  arthritis,  170,  189,  414,  475. 
Rheumatism,  acute,  170,  180,  189,  414,  475. 

scarlatinal,  178,  189. 
Rheumatoid  pains,  63,  381. 
Rhizoporus,  244. 
Rosa  anglica,  113. 

Roseola,  epidemic,  142,  148,  161,  180,  193,  194.     (See  "Rotheln.") 
febrilis,  148. 
vaccinal,  112. 
variolosa,  77. 
simple,  149,  201. 
Rose-raah — epidemic,  142,  148,  161,  193  ;  of  enteric  fever,  365,  369. 

simple,  149,  201. 
Rose's  vaccinator,  110. 


512  index  or  SUBJECTS. 

Rbtheln,  142,  148,  161,  180, 193  ;  nomenclature,  193  ;  definition,  193  ;  a  disease 
sui generis,  193,  200  ;  "breeds  true,"  193  ;  aetiology,  193  ;  clinical  history; 
195  ;  incubation,  195  ;  invasion,  196;  eruption,  196  ;  itching  in,  197, 
swelling  of  glands  in,  197  ;  desquamation,  197  ;  temperature,  197  ;  com- 
plications and  sequelae,  198  ;  pathology,  198  ;  diagnosis,  198  ;  prognosis, 
201  ;  treatment,  201. 

Rubeola  nigra,  143. 
notha,  194. 

Rubeoloid  rash  of  typhus,  258. 

Saccharomyces,  13. 

Saccharomycetes,  13. 

Salicin  in  enteric  fever,  458. 

Salicylate — of  bismuth,  443,  449.  466,  467  ;  of  magnesium,  444  ;  of  sodium — 
in  erysipelas,  223  ;  in  enteric  fever,  458. 

Salicylic  acid  in  enteric  fever,  458. 

Saline  cathartics,  52. 

Salivation  in  smallpox,  83. 

Salol  in  enteric  fever,  449,  458. 

Saprogenic  microbes,  15. 

Saprophytes,  14. 

Scaphoid  abdomen,  413. 

Scarlet  fever,  98,  148,  154.     (See  "  Scarlatina.") 

Scarlatina  anginosa,  159,  167,  186. 
faucium,  166. 

haemorrhagica,  168,  177,  188. 
maligna,  159,  168,  187. 
simplex,  158,  184. 
surgical,  157,  291,  374,  411. 

Scarlatina,  98,  148, 154;  nomenclature,  154;  definition,  154;  aetiology,  154 — 156; 
area  of  diffusion  of,  155  ;  rate  of  mortality,  155 ;  predisposing  causes,  156  ; 
exciting  cause,  157  ;  bacteriology  of,  158,  192  ;  clinical  history  :  incu- 
bation, 159  ;  invasion,  161  ;  eruption,  162  ;  defervescence  in,  163,  172  ; 
desquamation,  163  ;  relapse  in,  164  ;  irregular  and  aberrant  forms,  166  ; 
abortive  or  rudimentary,  166  ;  ataxic,  168  ;  haemorrhagic,  168  ;  compli- 
cations and  sequelae,  170  ;  pathology,  173;  urine  in,  177;  diagnosis  of, 
179  ;  prognosis,  181  ;  mortality,  181  ;  causes  of  death,  181  ;  treatment, 
182  ;  prophylaxis,  182  ;  curative  treatment,  183. 

Scarlatinal  dissolution  of  the  blood,  169,  172,  181. 

Scarlatine  fruste,  167. 

Schacht's  "  Liquor  bismuthi,"  224. 

"  Scharlach-typhus,"  169,  172,  181. 

Schizomycetes,  13,  14. 

Scotland,  deaths  from  relapsing  fever  in,  315. 

Season  as  a  predisposing  cause  of  disease,  71,  126,  135,  156,  205,  251,  316,  415. 


INDEX    OF   SUBJECTS.  hY?) 

Secondary  fever  in  smallpox,  88. 
Semi-confluent  smallpox,  82,  85. 
"  Semitertian  ague,"  342. 
Senile  enteric  fever,  407. 
Septicaemia,  96,  100  ;  typhoid,  421. 
Septicaemic  eruptions,  374,  375. 
Septic  endocarditis,  413. 

phlebitis,  145. 
Sequelae,  64,  85,  94,  129,  145,  171,  198,  284,  326,  395. 
Serous  membranes  in  smallpox,  81. 

Sex  as  a  predisposing  cause  of  disease,  204,  251,  349,  415. 
Shaven-beard  appearance  in  the  intestines  in  enteric  fever,  422,  427. 
Sheep  rot,  103. 
Sheffield  epidemic  of  smallpox,  74,  100,  105. 

typhus,  243. 
Simple  continued  fever,  98,  231-238.     (S^e  "  Febricula.") 
Singultus,  281. 

Sipping  of  water  for  constipation,  476. 

Skin— in  smallpox,  94,  96,  122  ;  in  typhus,  271  ;  in  enteric  fever,  369. 
Sleeplessness,  60,  123,  280,  381. 

Smallpox,  the  paradigm  of  the  eruptive  fevers,  68,  69,  148, 180,  411  ;  nomencla- 
ture, 69  ;  definition,  69  ;  aetiology,  70  ;  periodicity  of,  71  ;  seasons  and,  71 ; 
race  and,  72  ;  bacteriology  of,  73  ;  its  "  striking  distance,"  74 ;  chief  stages 
of  infectiveness,  75 ;  clinical  history,  75 ;  incubation,  75 ;  invasion,  76 ;  acci- 
dental rashes  in,  76  ;  stage  of  eruption,  78  ;  stage  of  desiccation,  80  ;  stage 
of  desquamation,  80 ;  classification  of,  82  ;  discrete,  82  ;  confluent,  82  ; 
salivation  in,  83 ;  mortality  in  confluent,  84  ;  sequelae  of,  85,  94,  95  ; 
coherent,  85  ;  corymbose,  86  ;  temperature  in,  87  ;  modified,  69,  89,  90  ; 
malignant,  90  ;  table  of  varieties  of,  93  ;  complications,  94,  95  ;  pathology, 
96  ;  diagnosis,  98,  180  ;  prognosis  of,  99  ;  prophylaxis,  102 ;  curative 
treatment,  113. 
"Smoky  urine,"  177. 
Soil-pipes,  432. 

Solid  food  after  enteric  fever,  477,  478. 
Somnolence,  280. 
Sordes,  277. ' 
Spaltpilze,  13. 
Specific  disease,  13,  16. 
fever,  2,  18. 
micro-organisms,  16. 
remedies,  53. 
Spirillum  buccale,  318. 

fever,  313,  318,  390.     (See  "Relapsing  Fever.)" 
Obermeieri,  318,  319. 

2l 


514  INDEX   OF   SUBJECTS. 

Spirochete  denticola,  318. 
Obermeieri,  319. 
plicatilis,  318,  329. 
Spleen — in  smallpox,  97  ;  in  relapsing  fever,  326,  390 ;  in  enteric  fever,  380, 

428  ;  abscess  of  the,  429. 
Splenic  dulness  in  enteric  fever,  365. 
Spleno-typhoid  fever,  406,  407,  422. 
Sponging,  tepid,  54,  306. 

Spontaneous  origin — of  fever,  232  ;  of  typhus,  247  ;  of  enteric  fever,  346,  356. 
Sporadic  disease,  19  ;  definition  of,  21. 
"Spores,  resting,"  16,  232,  249,  319,  354,  356. 
Sporulation,  16. 

St.  Giles  and  St.  Pan  eras,  scarlatina  in,  157. 
Stimulants,  use  of,  48,  58,  59,  310,  440,  477. 
Stimulation  in  fever,  48,  58,  59,  274,  310,  441,  477. 
Stomach  in  enteric  fever,  419. 
Stools  in  enteric  fever,  377. 
Strabismus,  283. 
"  Strawberry  tongue,"  163. 
Streptobacillus,  244. 
Streptococci  of  smallpox,  73  ;  of  scarlet  fever,  158,  192  ;  of  diphtheria,  168  ;  of 

erysipelas,  203,  209,  216  ;  of  typhus,  244. 
Streptococcus — scarlatinse,  158,  192  ;  diphtheria,  168  ;  erysipelatis,  203,  209, 

216  ;  conglomeratus,  192  ;  pyogenes,  217. 
"  Striking  distance  "  of  smallpox,  74  ;  of  measles,  134  ;  of  typhus,  245. 
Strophulus,  130. 
Strychnin  in  tympanites,  467. 
St.  Thomas's  Hospital,  131,  255. 
Stupor,  62. 

Subcuticular  mottling,  259. 
Subsultus  tendinum,  281. 
Sudamina,  271,  371. 
Sulphites  in  enteric  fever,  443,  445. 

Sulpho-carbolate  of  sodium— in  smallpox,  115  ;  in  erysipelas,  225. 
Sun  fever,  233,  236. 
Suppuration,  fever  of,  88. 
"  Surditas  salutem  portendit,"  283. 
Surgical— scarlatina,  157,  291,  374,  411 ;  erysipelas,  203. 
Susceptibility,  28,  30,  43,  102. 
Sympathetic  system  in  typhus,  302. 
Symptomatic  fever,  2. 

treatment,  49,  59. 


INDEX    OF    SUBJECTS.  515 

Synocha,  233,  235. 

Synovitis  acuta,  178. 

Syphilides,  pustular,  98. 

Syphilis,  69  ;  vaccine--,  112.  ' 

Sweating,  profuse,  in  typhus,  260,  267,  272. 

Table  of  varieties  of  smallpox,  93. 

Taohe  ce're'brale,  296,  413. 

Tache  scarlatinale,  162. 

Taches  bleuatres,  236,  272,  370,  371. 

Taches  rose'es  lenticul aires,  370. 

Tagsore,  103. 

Tank-bath,  454,  455. 

Tartar  emetic  and  opium,  60,  62,  266. 

Tartar  emetic  in  enteric  fever,  443. 

Taste,  283. 

Temperature,  behaviour  of,    in  febrile  disorders,  25. 

in  smallpox,  87  ;  chickenpox,  127  ;  measles,  146  ;  scarlatina,  171; 
Rotheln,  197  ;  erysipelas,  213  ;  typhus,  263  ;  relapsing  fever,  325  ; 
enteric  fever,  392,  408,  409. 
reduction  of,  48,  52,  223,  450. 
Tepid  sponging,  54. 

Terling,  Essex,  outbreak  of  enteric  fever  at,  350. 
Thallin,  459. 
Theory  of  animal  heat,  4. 

disease,  germ,  12,  13. 

fevers,  3,  4. 

immunity,  21,  434,  482. 
Thermal  apparatus,  5. 

nervous  system,  5. 
Thermogenesis,  5. 
Thermolysis,  5. 
Thermotaxis,  5. 

Thiocamf  as  a  disinfectant,  34,  35. 

Thirst  in  fever,  9,  10 — how  explained,  10  ;  how  relieved,  63. 
Thoracentesis,  191. 
Thoracic  form  of  enteric  fever,  395. 
Thrombosis,  287,  312,  398. 
Thymic  acid  in  enteric  fever,  460. 
Thymol  in  enteric  fever,  448. 
Tinnitus  aurium,  258,  321,  383; 
"  Tippet-neck,"  168. 


516  INDEX  OF  SUBJECTS. 

Tisanes,  439. 

Tissue  disintegration,  4. 

formation,  4, 
Tongue  —in  scarlatina,  163  ;  in  typhus,  277  ;  in  relapsing  fever,  321  ;  in  enteric 

fever,  365, 
Tonsillitis,  180. 
Tooth-paste,  antiseptic,  437. 
Torula  cerevisise,  13. 
Toxic  microbes,  15. 
Toxins,  15,  16,  22. 

Transfusion  of  blood  in  smallpox,  124;  in  enteric  fever,  470. 
Traumatic — scarlatina,  157  ;  erysipelas,  203. 
Traumatism  in  erysipelas,  203,  204. 

"surgical  scarlatina,"  157, 
Treatment,  cold  water,  53. 

curative,  48,  113,  132,  150,  183,  201,  221,  237,  306,  330,  435. 
ectrotic,  225. 
expectant,  184,  221,  330. 

preventive,  30,  40,  47,  102,  150,  305,  330,  430, 
principles  of,  48,  113. 
symptomatic,  59. 
Tremor,  inordinate,  in  enteric  fever,  366, 
Trichiniasis,  413. 
Tubercle,  pulmonary,  %96. 

Tuberculosis,  acute  miliary,   129,  146,  153,  286,  396,  413. 
Turkey,  103. 

Turpentine,  467,  468;  in  enteric  fever,  443,  445,  468. 
Turpentine  and  ergot  in  smallpox,  123  ;  in  enteric  fever,  470, 
"  Twining's  pill,"  333. 
"Twisting  of  the  guts,"  324. 
Tympanites,  63,  280,376,  467. 
"  Typhisation  a  petite  dose,"  245,  253,  294. 
Typhoid,  bilious,  317,  318,  320,  322  323, 328,  334, 

remittent  fever,  295. 
Typhoid  fever,  339, 340.     (See  "  Enteric  fever.") 
matter,  424. 
pneumonia,  296. 
scarJatima,  172. 
septicaemia,  421. 
stage  of  typhus,  259. 

state,  58,  61,  62  143,  260,  303,  329,  336,  369y  376, 
ulcer,  422,  424. 


INDEX    OF    SUBJECTS.  517 

Typho-malarial  fever,  401,  405. 

Typhomania,  83,  259,  279. 

Typhus,  149,  229-232,  239,  328,  337,  411 ;  nomenclature,  239  ;  definition,  241 
literature,  242  ;  geographical  distribution.  242  ;    aetiology,  243  ;  poison  of, 
facts  known  about,  244,  245  ;  supposed  spontaneous  origin  of,  247  ;  pre 
disposing  causes  of,  251  ;  clinical  description  of,  255  ;  incubation  of,  255 
invasion  of,  257  ;   eruption,  258  ;    stage  of  nervous  prostration  in,  259 
defervescence  or  crisis,  260  ;  convalescence,  261  ;  duration,  261  ;  siderans, 
262,  293  ;  relapses  in,  263  ;  temperature  in,  263  ;  pseudo-crisis  in,   263 
hyperpyrexia  in,  265  ;    analysis  of   symptoms  in,  271  ;    physiognomy  of, 
271  ;  odour  of,  272  ;  levissimus,  234,  294  ;  pulse  in,  273  ;  heart  in,  273 
breathing  in,  259,  275  ;  breath  in,  276  ;  digestive  system,  276;  urine  in 
258,  277  ;    nervous  system  in,  278  ;   complications  and  sequelae  of,   284 
varieties    of,    293 ;    comatosus,    293  ;    catarrhal,    294  ;    diagnosis,    294 
prognosis  and  mortality,  296  ;  pathology,  300  ;  emaciation  in,  300 ;  treat- 
ment, 305. 

"  Typhus  ambulatorius,"  406. 

Typhus  headache,  256,  278. 

Ty rosin,  278. 

Ujnala,  tragedy  of,  249. 

Ulceration  and  sloughing  in  enteric  fever,  366. 

Ulcerative  endocarditis,  413. 

laryngitis,  396. 
"  Ulcer,  typhoid,"  422,  424. 
Underground  water  and  enteric  fever,  350. 
Uraemia,  176,  290,  296. 

preventive  treatment  of,  190. 
Urea,  excretion  of,  277. 
Urine,  incontinence  of,  311. 

in  scarlatina,  170,  174,  175,  176,  177. 

retention  of,  282. 

in  typhus,  258,  277  ;  in  enteric  fever,  380,  381. 
Urticaria,  or  nettlerasu,  219,  371 ;  febrile,  373. 

Vaccina,  105,  111. 

Vaccinal — cicatrices,  108,  111  ;  roseola,  112  ;  lichen,  112 ;  herpes,  112. 

Vaccination,  104,  105,  109,  110. 

Act,  103,  109. 

influence  of,  on  whooping-cough,  2S ;  on  smallpox,  105, 106, 107, 108- 
Vaccinator,  110. 
Vaccine  pen,  110. 
Vaccino-syphilis,  112. 
"  Vaccuolo,"  103. 


$18  INDEX    OF   SUBJECTS. 

Varicella,  98,  125,  127,  149.     (See  "  Chickenpox.") 
emphysematosa,  128. 
gangraenosa,  129. 
prurigo,  130. 
ventosa,  128. 
Varieties  of  smallpox,  82,  89,  93  ;  of  measles,  142  ;  of  scarlatina,  166  ;  of  ery 

sipelas,  210  ;  of  typhus,  293  ;  of  enteric  fever,  405. 
Variola,  69,  70,  291.     (See  "  Smallpox.") 
benigna,  89. 

cornea,  89.  , 

crystallina,  82. 
haemorrhagica,  90,  91. 

pustulosa,  92. 
maligna,  90. 
ovina,  73,  103,  104. 
purpurica,  90,  91. 
sine  exanthemate,  89. 
sine  variolis,  89. 
verrucosa,  89. 
Variolas  cruentse,  93. 
equinae,  104. 
nigrae,  93. 
ovinse,  73,  103,  104. 
pusilla?,  126. 
vaccinae,  104. 
Variole  modifie'e,  89. 
Varioloid,  69,  89,  90,  130. 
Venesection,  52. 

"  Venienti  occurrite  moroo,"  310. 
Venous  thrombosis,  287,  312,  398. 
Ventilation,  41,  42,  306. 

constant  or  natural.  42. 
defective,  39. 
occasional,  42. 
Veratria,  460. 
Vertigo,  279. 
Vesical  catarrh,  402. 
Vibices,  272,  371. 
Vienna  General  Hospital,  118,  122. 
Virus,  8,  13,  43. 

attenuated,  43,  103. 
Voluntary  muscles  in  enteric  fever,  417. 
Vomiting,  63,  376,  399,  469. 

of  blood,  289. 
Vulva,  gangrene  of  the,  146,  153. 


INDEX    OF   SUBJECTS.  519 


Wakefulness,  280. 

Wartpox,  89,  90. 

Warts,  shedding  of,  173. 

Waste,  4. 

Wasting  of  fever — how  explained,  9. 

Waterclosets,  432. 

Water,  cold,  treatment  of  fever,  53,  309,  310,  450. 

how  to  be  supplied  to  the  fever  patient,  10,  439. 

supply,  40,  432. 

uses  of,  in  fever,  10,  53,  439,  450. 
Wet-cupping,  52. 
Wet-pack,  54,  451. 
"  White  blisters,"  129. 

Whooping-cough,  influence  of  vaccination  on,  28. 
Windpox,  128. 
"  Worm  fever,"  407. 

Yeasts,  13. 

Yellow  fever  of  the  British  Islands,  324,  328. 

Ziehl-Neelsen  test,  413. 
"Zyme,"  13. 

Zymine  peptonising  powders,  438. 
Zymogenic  microbes,  15. 
Zymotic  diseases,  12,  13,  18. 


INDEX   OF   NAMES. 


Abbott,  A.  C.,  482,  485. 

Addison,  161. 

Aitken,  Sir  William,  132,  194,  196,  200. 

Alison,  58,  283,  299. 

Allbutt,  Clifford,  403. 

Allen,  of  Melbourne,  358. 

Anderson,  M'Call,  372. 

Andrew,  James,  303. 

Areber,  Robert  S.,  427,  429. 

Arrnitage,  62. 

Armstrong,  293. 

Ashby,  165. 

Atthill,  Lombe,  124. 

Aulnas,  Claudien,  375. 

Auspitz,  96. 

Autenrieth,  341. 

Avicenna,  2,  133. 

Baader,  of  Basle,  125. 

Babes,  134. 

Bacon,  Lord  Chancellor,  247. 

Baglivi,  331,  435,  463. 

Ballard,  Edward,  136,  156,  358. 

Banks,  Sir  John,  117. 

von  Barensprung,  97. 

Barker,  F.,  314,  315. 

Barlow,  H.  C,  343. 

Barrallier,  261,  272,  281,  293,  294,  302,  343. 

Barr,  James,  454,  455,  457. 

Barry,  75,  100. 

Barthez,  165,  171,  174,  290,  379,  383,  458. 

Bartleet,  472,  473. 

Bartlett,  351,  395. 

Basch,  96. 

Basin,  372. 


INDEX    OF   NAMES.  521 


Bastian,  Charlton,  216. 

Bateman,  128,  143,  16?,  169,  239,  247. 

Beck,  397. 

Begbie,  Warburton,  287. 

Behring,  Stabsarzt  Dr.,  37. 

Bell,  Hamilton,  222. 

BelloniuB,  340. 

Benson,  J.  Hawtrey,  120. 

Bertrand,  117. 

Beumer,  352. 

Beveridge,  302. 

Bewley,  H.  T.,  367,  394. 

Bicker,  173. 

Biermer,  174,  176. 

Biesiadecki,  215. 

Billroth,  202,  217,  220. 

Binz,  222. 

Blane,  Sir  Gilbert,  241,  247. 

Blyth,  A.  Wynter,  23,  42,  74,  431. 

Bochefontaine,  223. 

Bock,  330. 

Bocker,  11. 

Boddie,  G.  P.,  164. 

Boerhaave,  of  Leyden,  70,  78,  233. 

Bonfigli,  225. 

Bontecou,  472,  473. 

Borgien,  225. 

Borsieri,  193,  200,  203,  218,  240,  241. 

Bouchard,  441,  443,  447,  452. 

Bouchut,  162. 

Boyce,  of  Edinburgh,  126. 

Bozzolo,  353. 

Braidwood,  374. 

Brand,  Ernst  (of  Stettin),  54,  451. 

Brattler,  380. 

Bretonneau,  340,  342,  422. 

Bristowe,  J.  S.,  127. 

Brouardel,  359. 

Broussais,  340,  342,  390,  417. 

Brown,  341. 

Bruce,  J.  Mitchell,  178,  179. 

Brunton,  Lauder,  8,  455,  476,  480. 


522  INDEX   OF   NAMES. 

Buchanan,  158,  263,  350. 

Buchner,  485. 

Budd,  Wm,  340,  351,  424. 

Buhl,  350. 

Burnett,  233. 

Burserius,  240,  241. 

Busk,  218. 

Cameron,  Sir  Charles  A.,  358,  362. 

Canstatt,  129. 

Cantani,  Arnoldo,  6,  53,  450,  458. 

Cardanus,  240. 

Carpenter,  Alfred,  374. 

Carpenter,  W.  B.,  38,  40. 

Carter,  Vandyke,  313,  318,  320,  329. 

Cayley,  William,  64,  244,  249,  251,  283,  300,  329,  342,  343,  345,  355,  359,  363, 

394,  397,  403,  414,  415,  451,  456,  457,  459,  468. 
Celli,  19. 

Chantemesse,  353,  360,  421. 
Chauffard,  452. 
Chauveau,  73. 

Cheyne,  John,  314,  315,  331,  332,  340. 
Cheyne,  Watson,  *217,  351. 
Chomel,  218,  280,  340,  397,  406,  423,  425. 
Christian,  E.  P.,  359. 
Christison,  Sir  Robert,  320. 
Churchill,  Fleetwood,  146. 
Clarke,  J.  Michell,  443,  444. 
Cleveland,  Clement,  447. 
Coats,  176,  352. 
Cohn,  73,  216,  318,  319. 
Cohnheim,  413. 
Collie,  Alexander,  289,  345. 
Conolly,  J.,  81,  86. 
Copland,  195,  225,  233,  340. 
Cormack,  322. 
Cornil,  134,  211. 

Corrigan,  Sir  Dominic,  259,  275,  282,  288,  474 
Coze,  158,  352. 
Craigie,  291,  340. 

Crocker,  Radcliffe,  130,  371,  372,  374. 
Croly,  Henry  Gray,  168,  191. 


INDEX    OF   NAMES.  523 

Crooke,  352. 

Crookshank,  Edgar  M.,  15,  22,  73,  104,  134,  320. 

Cruveilhier,  340,  420. 

Cullen,  67,  68, 154,  231,  233,  239,  247,  313,  340. 

Curschmann,  75,  77,  78,  79,  80,  81,  83,  89,  90,  92,  96,  97,  117,  123,  124. 

Currie,  56,  450,  451. 

Czakert,  126. 

Dahne,  185. 

Danchersen,  317. 

Davasse,  233,  236. 

Davies,  D.,  of  Bristol,  249,  257. 

Day,  John  Marshall,  297,  402,  415. 

Debove,  452. 

De  Haen,  92. 

Deiters,  174. 

Delavigne,  Casimir,  109. 

Delpech,  131. 

Dieulafoy,  403. 

Dujardin-Beaumetz,  435. 

Ebel,  340. 

Eberth,  342,  352-354,  356,  359,  360,  447. 

Ebstein,  263. 

Ehrenberg,  216,  318. 

Ehrlich,  409. 

Eichhorst,  388. 

Eimer,  77. 

Eiselt  of  Prague,  406. 

Ellis,  Edward,  197. 

Emmerich,  485. 

Engel,  317. 

Eppinger,  352. 

Esher,  473. 

Estlander,  J.  A.,  326. 

Evans,  340. 

Ewald,  C.  A.,  313,  330. 

Fagge,  C.  Hilton,  3,  76,  77,  79,  86,  89,  96,  97,  121,  125,  127,  128,  130,  131, 
134,  138,  139,  143,  147,  150,  161,  164-166,  169,  173,  195.  204,  218,  219, 
340,  344,  346,  357,  363,  365,  367,  368,  407,  414-416,  420,  422,  424,  427, 
428,  439,  449,  451,  460,  463,  477,  481. 

Falconer,  John,  426. 


524  INDEX   OF   NAMES. 

Fardon,  E.  A.,  457. 

Farr,  William,  313. 

Fehleisen,  203,  209,  216. 

Feltz,  158,  352. 

Fenwick,  Samuel,  54,  55,  173,  187,  188,  191,  225,  466. 

Filehne,  Wilhelm,  459. 

Finlay,  414. 

Fleischmann,  126. 

Flint,  Austin,  3,  189,  340,  395,  400. 

Fliigge,  C,  351,  355. 

Foot,  Arthur  Wynne,  114,  117,  269. 

Fordyce,  233,  416. 

Forestus,  133,  340. 

Forget,  399. 

Fothergill,  168. 

Fowitsky,  485. 

Fracastori,  240,  283. 

Fraukel,  352,  354. 

Frantzel,  395. 

Frank,  John  Peter,  92,  218. 

Frerichs,  190,  278. 

Friedlander,  352. 

Friedrich,  472. 

Fiirbringer,  165. 

Gaddesden,  John  of,  113. 

Gaffky,  351,  352-357,  360,  362. 

Gairdner,  W.  T.,  292,  397,  399. 

Galen,  2,  9,  83,  259,  263,  279,  342,  382. 

Gee,  Samuel,  128,  132. 

Gerhard,  272,  343. 

Gerhardt,  126. 

Gerin-B,ose,  452. 

Gibson,  208. 

Giersing,  182. 

Giglio,  Joseph,  354. 

Gilchrist,  340. 

Godelle,  182. 

Goltdammer,  453,  456. 

Goodfellow,  205. 

Gore,  Albert  A.,  345. 

Gramshaw,  F.  Sidney,  443,  44 


INDEX   OF   NAMES.  525 

Grancher,  of  Paris,  447,  448, 

Grant,  William,  241,  247. 

Graves,  Kobert  J.,  57,  58,  60,  62,  116,  12:3,  152,  155,  166,  205,  226,  243,  259, 

266,  275,  282,  291,  296,  307,  313,  315,  317,  324,  331,  332,  335,  378,  416. 
Gregory,  127. 

Griesinger,  242,  310,  320,  323,  328,  334,  341,  373,  377,  388,  400. 
Grimshaw.  T.  W.,  Registrar-General  for  Ireland,  106,  107,  135,  136,  251,  252 

315,  330,  346,  349,  357,  464,  466. 
Griscom,  225. 
Gubler,  203,  204. 
Gueniot,  374. 
Gull,  Sir  William,  414. 
Gumprecht,  165. 
Gimther,  413. 
Guttmann,  380. 
Guyot,  373. 

Halm,  473. 

Hahnemann,  183. 

Haight,  218. 

Haller,  of  Vienna,  245. 

Hallier,  244. 

Hallopeau,  223,  226. 

Hamernjk,  389. 

Hardy,  372. 

Hare,  F.  E.,  453,  454. 

Harkin,  Alexander,  189. 

Harvey,  Physician-General,  478. 

Harvey,  Reuben  J.,  100,  256,  393. 

Hasse,  225. 

Hawkins,  Csesar,  74. 

Hawksley,  457. 

Hayem,  397,  452. 

Heberden,  William,  75,  126,  154. 

Hebra,  54,  75,  77,  90,  94,  110,  111,  118-122,  181,  137,  139,  141,  143,  147,  169, 

181,  183,  184. 
Heim,  126. 

Henn,  Edmund  P.,  426. 
Henoch,  E.,  128,  164,  178. 
Henry,  F.,  448. 
Henry,  W.,  246. 
Hermann,  300. 


526  INDEX   OF  NAMES. 

Hesse,  of  Leipzig,  126. 

Hewett,  of  London,  406. 

Hewitt,  of  Minnesota,  74. 

Heyfelder,  220. 

Hicks,  ill. 

Higginbottom,  225. 

von  Hildenbrand,  193,  234,  239,  242,  253,  260,  294,  309,  342. 

Hippocrates  of  Cos,  2,  202,  219,  233,  234,  239,  281,  342,  381. 

Hirsch,  70,  73,  133,  155.  157,  204,  205,  208,  240,  242,  243,  295,  313,  316-318, 

344. 
Hirtz,  Edgar,  449. 
Hlava,  244. 
Hoffa,  157. 

Hoffmann,  F.,  230,  233,  368,  403,  418. 
van  Hook,  473. 
Hoppe-Seyler,  442. 
Hopwood,  E.  O.,  165. 
Howard,  Warrington,  130. 
Howard,  John,  241. 
Hoyer,  235. 

Huchard,  444,  461,  462. 

Hudson,  Alfred,  117,  206,  225,  226,  237,  248,  275,  288,  311,  351,  377,  390, 
391,  466. 

Hiiter,  216,  225. 

Hufeland,  182,  241. 

Huguenin,  177,  359. 

Human,  388. 

Hunter,  John,  28,  404. 

Huss,  63. 

Hutchinson,  480. 

Hutchinson,  Jonathan,  129,  130,  290. 

Huxham,  83,  118,  122,  233,  247,  340. 

Hyde,  James  Nevins,  372. 

Illingworth,  C.  R,  183. 
Ingrassias,  126,  154,  234. 

Jaccoud,  165,  388. 

Jacob,  Arthur,  326. 

Jacquot,  245,  248,  253,  261,  272,  288,  294. 

von  Jaksch,  319,  352,  353. 

Jamieson,  236. 


INDEX   OF  NAMES.  527 

Janeway,  448. 

Jenkins,  J.  H.,  470. 

Jenner,  Edward,  105,  109,  111. 

Jenner,  Sir  William,  169,  259,  263,  280,  289.  296,  343,  366,  377,  381,  413. 

Jesty,  Benjamin,  105. 

John  of  Gaddesden,  113. 

Josias,  452. 

Juhel-Renoy,  452. 

Jiirgensen,  451. 

Kanz,  340. 

Kaposi,  131. 

Karlinski,  353. 

Keating,  134,  380. 

Kelly,  of  Mullingar,  321. 

Kennedy,  Henry,  288,  378. 

Kesteven,  448. 

Kimura,  473. 

Kirkpatrick,  Frederick,  443. 

Klebs,  19,  174,  176,  352. 

Klein,  73,  158,  170,  175-177,  352. 

Klemperer  and  Klemperer,  482-485. 

Koch,  22,  209,  352,  354,  360. 

Konig,  B.,  204,  205. 

Korner,  164. 

Kronecker,  476. 

Kiittner,  196. 

Kurth,  H.,  192. 

Kussmaul,  472. 

Laennec,  362. 

Landenberger,  173. 

Langenbeck,  Max,  187. 

Langrish,  233. 

Laptachinski,  M.,  390. 

Lawrence,  214. 

Lawrie,  Edward,  443. 

Lawson,  Robert,  19. 

Laycock,  241,  480. 

Lebert,  H.,  242,  251,  262,  301,  306,  313,  318,  320,  330,  332-334. 

Lees,  Cathcart,  324. 

Lefort,  Paul,  151,  224,  452. 

Legrain,  359. 


528  INDEX   OF   NAMES. 

Lentin,  173. 

Leroux,  444. 

Lesser,  440. 

Levy,  217. 

Lewentauer,  117. 

Lewin,  141. 

Leyden,  276,  472. 

Liebermiester,  3,  18,  19,  55,  222,  337,   338,  344,  350,  363,  370,  372,  376,  377, 

378,  379,  381,  396,  398,  399,  402,  403,  408,  422-424,  428,  430,  436,  438, 

440,  441,  447,  459,  460,  466,  468,  472. 
Liddell  and  Scott,  202. 
Lieutaud,  233. 
Lind,  239,  241,  272. 
Lindwurm,  242. 
Little,  James,  416,  466,  471. 
LitUejohn,  H.,  359. 

Liveing,  Robert,  16,  99,  195,  196,  198,  200. 
Loeff,  73. 
Loffler,  168. 
Lombard,  H.  C,  343. 
Longmans,  Green  &  Co.,  251. 
Lorain,  Paul,  215. 
Loschner,  173,  181. 

Louis,  P.  A.  C,  273,  340,  343,  370,  377,  383,  396,  402,  406,  419,  423,  429. 
Luchhan,  327. 
Liicke,  225,  473. 
Lukomsky,  209. 
Lyons,  R.  D.,  63,  325,  399. 
Lysons,  Daniel,  62. 

Macalister,  Donald,  3,  5,  6. 

Mackenzie,    26. 

Maclagan,  T.  J.,  4,  5,  9,  10,  261,  388,  389,  423. 

MacSwiney,  S.  M.,  385. 

Mahomet,  70. 

Magonty,  440. 

Makuna,  127. 

Malcolm,  A.,  276. 

Marchiafava,  19. 

Marius,  of  Avenches,  70. 

Marmy,  302. 

Martin,  Sir  Ranald,  233,  238. 


INDEX   OF   NAMES.  52i) 

Martindale,  459,    460,  402. 

Marshal],  John,  278. 

Marson,  86,  89,  92,108,  117. 

Massa,  N.,  240. 

Maunsell,  340. 

Mayr,  54,  139,  147,  169,  181,  183. 

Mears,  Ewing,  472. 

Mercatus,  20, 

Mertens,  144. 

MetschnikotT,  Elias,  22,  217,  218. 

Meyer,  J.,  11,  352,  354,  360. 

Michel,  351,  389. 

Mikulicz,  473. 

Millard,  452. 

Mohl  of  Copenhagen,  131. 

Monneret,  468. 

Monro,  D.,  247. 

Montague,  Lady  Mary  Wortley.  22,  103. 

Moore,  William  Daniel,  160,  350. 

Morehead,  238. 

Morgan,  Campbell  de,  205,  218,  222. 

Morton,  83,  154. 

Morton,  of  Philadelphia,  472,  473, 

Motschutkovsky,  of  Odessa,  245,  320,  324. 

Mosler,  of  Greifswald,  250,  309. 

Mott,  244. 

Moutard-Martin,  373. 

Muller,  110. 

Murchison,  Charles,  2,  5,  9,  21,  39,  41,  42,  48,  49,  52,  58,  59,  61,  6a,  64,  68,  85, 
149,  159,  160,  163,  195,  198,  230,  231,  235,  236,  237,  238,  239,  242,  243, 
244,  245,  246,  247,  248,  249,  251,  252,  253,  255,  257,  260,  261,  262,  263, 
265,  269,  270,  271,  272,  275,  276,  277,  278,  279,  281,  283,  284,  286,  287, 
288,  289,  291,  292,  296,  298,  300,  301,  302,  303,  305,  308,  309,  313,  316, 
320,  325,  326,  327,  329,  330,  331,  332,  333,  336,  339,  340,  341,  342,  343, 
344,  345,  346,  349,  350,  355,  357,  363,  364,  365,  366,  367,  368,  369,  370, 
372,  376,  377,  378,  380.  383,  384,  388,  389,  394,  395,  396,  398,  399,  400, 
401,  402,  403,  404,  407,  411,  413,  414,  415,  417,  419,  420,  422,  423,  424, 
425,  427,  429,  435,  446,  451,  457,  463,  465,  466,  468,  469,  470,  471,  477, 
478,  481. 

Nageli,  13.  ,: 

Natanson,  449. 
Nelaton,  208,  373. 

2   M 


530  INDEX   OF  NAMES. 

Nelson.  E.,  446. 

Nencki,  14. 

Neuhaus,  353. 

Neumann,  353. 

Niemeyer,  139,  142,  250,  257,  294,  321,  323,  332,  402,  441,  442,  480. 

Nixon,  C.  J.,  404. 

Nothnagel,  170,  398,  399. 

von  Noorden,  216. 

Nunneley,  225. 

Nystrom,  225. 

Obermeier,  159,  313,  318,  319,  322,  325. 

O'Brien,  317. 

Oertel,  168,  188. 

Ogston,  216. 

Orleans,  Duke  of,  103. 

Orlow,  193. 

Ormerod,  313. 

Orth,  209. 

Paget,  Sir  James,  403. 

Panum,  of  Copenhagen,  135,  137. 

Paris,  M.  le  Docteur,  208. 

Parkes,  Edmund  A.,  231,  380. 

Pasteur,  15,  22. 

Paterson,  Robert,  194,  195. 

Paul,  351. 

Pavy,  F.  W.,  439,  479. 

Peacock,  292. 

Peebles,  229,  240. 

Pe"cholier,  448. 

Peiper,  352. 

Pennock,  343. 

Perry,  P.,  245,  281,  343. 

Peter,  of  Paris,  64,  146,  213,  468. 

Petit,  342. 

von  Pettenkofer,  350.' 

Pfeiffer,  73. 

Pfleger,  217. 

Phillips,  Sidney,  421. 

Piedvache,  351. 

Pinel,  240,  340. 


INDEX   OF    NAMES.  531 

Piorry,  340. 

Piquer,  233. 

Pohl-Pincus,  158. 

Polli,  of  Milan,  443,  445.     , 

Ponfick,  97,  215. 

Popbam,  243. 

Porter,  William  H.,  191. 

Powell,  Douglas,  132. 

Power,  157. 

Pringle,  J.  J.,  203,  211,  351. 

Pringle,  Sir  John,  241,  242,  247,  340. 

Procopius,  70. 

Pye-Smith,  414. 

Quincke,  363. 
Quist,  73. 

Rasori,  240,  242. 

Payer,  77. 

Raymond,  373. 

von  Recklinghausen,  352. 

Redmond,  J.  M.,  387. 

Registrar-General  for  England,  71,  136,  156,  340,  349. 

Scotland,  340. 

Ireland,  106,  107,  135    136,251  252  315  340,  346,  349, 
464,  466. 
Reher,  353. 
Reuss,  240,  241. 
Reynolds,  Emerson,  32,  410  . 
Rhazes,  70,  118,  133. 
Richter,  216,  340. 
Ricord,  225. 
Ridley,  John,  166. 
Riess,  330. 
Ringer,  Sydney,  54. 

Rilliet,  165,  171,  174,  290,  379,  383,  458, 
Rindfleisch,  97. 
Ritchie,  340. 
Ritzmann,  214. 
Riverius,  233,  295,  340. 
Robert  of  Marseilles,  81. 
Roberts,  F.  T.,  210,  220. 


.532 


INDEX   OF  NAMES. 


Robinson,  Bryan,  103. 

Rokitansky,  284,  '286,  294,  301,  397,  402,  425,  429. 

Romberg,  189. 

Rosenbaeh,  455. 

Rossi,  239. 

Roupell,  229,  240,  288. 

Roux,  E.,  10. 

Riitimeyer,  353. 

Russell,  J.  K,  288,  470. 

Rutty,  John,  313,  ai4,  34a 

Sajous,  453. 

Salisbury,  of  Newark,  134. 

Samuel,  3,  6. 

Sanderson,  Burdon,  73. 

Sarnow,  319. 

Sauer,  440. 

Saundby,  190,  372. 

Sauvages,  Boissier  de,  133,  154,  233,  239-241,    40. 

Scbneeman,  of  Hanover,  185. 

Schonlein,  340,  377. 

Schiitz,  229. 

Scriven,  233,  236. 

See,  Marc,  of  Paris,  224. 

Seidl,  Professor,  146. 

Seitz,  194,  352. 

Selmi,  479. 

Senator,  453. 

Senn,  473. 

Sennertus,  233,  240,  241. 

Serres,  342. 

Shattuek,  343,  388. 

Shelly,  C.  E„  31,  32,  112. 

Simmonds,  352. 

Simon,  G.,  148. 

Simon,  Th.,.  of  Hamburg,  77, 

Siredey,  373. 

Skoda,  118. 

Smart,  Charles,  344,  401. 

Smith,  Eustace,  129,  183. 

Smith,  Greig,  473. 

Smith,  J.  Lewis,  126,  194-198. 


INDEX    OF   NAMES.  533 

Smith,  Walter  G.,  170,  216,  471. 

Smyly,  Josiah,  119. 

de  Souza,  A.,  458. 

Spear,  John,  336,  337. 

Spender,  Kent,  443. 

Squire,  J.  Edward,  405. 

Squire,  William,  68. 

Stanger,  247. 

Starr,  Louis,  185. 

Steudener,  215,  218. 

Stein,  472. 

Steinberg,  318. 

Steiner,  126. 

Stewart,  Alexander  P.,  261,  263,  340,  343,  404. 

Stoker,  William,  298. 

Stokes,  Whitley,  129. 

Stokes,  William,  56,  58,  84, 115,  116,  119,  120,  123,  206,  264,  269,  273,  274,  282, 

283,  284,  285,  286,  287,  301,  302,  303,  309,  310,  313,  315,  324,  325,  335, 

396,  397,  421,  477,  478. 
Stork,  245. 
Stromeyer,  438. 
Strother,  233,  234,  240,  340. 
Strumpell,  68,  170,  236. 
Struve,  395. 
van  Swieten,  104. 
Sydenham,  Thomas,  69,  77,  78,  82,  92,  93,  114,  133,  139, 143,  149,  154,  155, 156, 

181,  247. 
Szadek,  192. 

Talamon,  118,  226. 

Taylor,  F.  Howard,  410. 

Tennent,  G.  P.,  of  Glasgow,  325. 

Testi,  448. 

Thomas,  of  Leipzig,  125,  126,  127,  128,  129,  134,  138, 139,  140,  141,  142,  143, 

147,  148,  149,  162,  164,  167,  169,  173,  189,  191,  193,  194,  195,  196,  201. 

459. 

Thomson,  John,  of  Edinburgh,   178. 

Thomson,  Theodore,  of  Sheffield,  213.    . 

Thome,  E.  Thorne,  350. 

Tillmanns,  209. 

Todd,  58,  62,  464. 

Tommasi-Ciudeli,  19. 

Tordeus,  of  Brussels,  460. 


534  INDEX    OF   NAMES. 

Toussaint,  22. 

Traube,  3,  263,  440. 

Trojanowsky,  141,  164. 

Trousseau,  68,  77,  78,  79,  82,  83,  84,  85,  90,  94,  95,  100, 104,  109, 126,  127. 12*. 
129, 130,  131,  140,  142, 144,  145, 149, 152,  159, 161. 162,  167, 187, 190, 191, 
193, 194,  195,  197,  200,  203,  208.  212,  214,  215,  216,  218,  220,  221,  226,  342, 
350,  368,  370,  371,  378,  397,  399,  403,  407,  422,  463,  465,  477. 

Trelat,  157,  374. 

Tschamer,  126. 

Tweedie,  Alexander,  166,  252. 

Uffelmann,  433. 

Vaillard,  421. 

Velpeau,  220,  223. 

Verneuil,  374. 

Verson,  E.,  423. 

Vetter,  126. 

Vidal,  353. 

Vidu-  Vidins,  126. 

Vierordt,  276. 

Vincent,  A.,  359. 

Virchow,  3,  215,  242,  318,  327,  362. 

Vogel,  A.,  85,  127,  154,  163,  272. 

Vogt,  W.,  447,  460. 

Voit,  9. 

Volkmann,  204,  205,  214,  215,  216,  218,  220,  223. 

Wagner,  E.  ,  175,  176,  418. 

Walford,  W.  G.,  183. 

Wassiljeff,  442. 

Watson,  Sir  Thomas,  73,  111,  113,  162,  203,  212,  224,  313,  446. 

Weigert,  73. 

Weil,  380. 

Wells,  205. 

Wendt,  81,  191. 

Werner,  Emil,  410. 

West,  Charles,  116,  152,  185,  402,  407. 

Westerland,  225. 

Whipham,  Thomas,  372. 

White,  George  B.,  448. 

Whitla,  Wm.,  446. 

Wilde,  225. 


INDEX    OF   NAMES.  535 

Wilks,  George,  of  Ashforrt,  Kent,  445. 

Wilks,  Samuel,  77,  163,  215,  340,  376,  397. 

Willan,  128,  140,  143,  162,  16t>. 

Willau  and  Bateman,  128,  143,  162,  169. 

von  Willebrand,  440. 

Wilson,  J.  C,  379. 

Withering,  154. 

Wolff,  448. 

Wolfler,  A.,  226. 

Wood,  George  B.,  446,  467. 

Wood,  Horatio  C,  10,  11,  278,  446. 

Woodbury,  F.,  480. 

Woodhead,  German  Sims,  41,  354. 

Woodman,  Bathurst,  1G9,  172,  194,  211. 

Woodward,  405. 

Wright,  G.  A.,  165. 

Wunderlich,  25,  26,  76,  87,  89,  138, 146,  163,  169,  171,  172.  187.  194,  213,  261, 

264,  265,  269,  270,  326,  366,  392,  394,  408,  409,  440-442,  459. 
Wutzer,  214. 
Wyss,  330. 

Yeo,  Gerald  F.,  390. 

Yeo,  J.  Burney,  50,  444,  446,  447,  448. 

Zawilski,  476. 

Zenker,  179,  303,  417,  418. 

Ziehl-Neelsen,  413. 

von  Ziemssen,  55,  195,  204,  376,  437,  440,  441,  470,  479. 

Zopf,  14. 

Zuelzer,  204,  205,  215,  220,  225,  244,  325,  342,  344,  351,  379,  413. 


Printed  by  John  Falconer,  53  Upper  Sackvllle-street,  Dublin. 


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